Chicoine, Dorothy PERMIT MUST ACCOMPANY REMAINS TO DESTINATION
FORM BT-1,12/2010
STATE OF NEW HAMPSHIRE 1.BURIAL PERMIT NO
BURIAL TRANSIT PERMIT 2.CITY OR TOWN
3.DECEDENT'S NAME(First,Middle,Last) 4.SEX 5.DATE OF DEATH(Month,Day,Year)
DOROTHY CHICOINE FEMALE AUGUST 1,2011
6.AGE 7.DATE OF BIRTH(Month,Day,Year) 8.CITY,TOWN,OR LOCATION OF DEATH 9.COUNTY OF DEATH
92 Years NOVEMBER 20,1918 ROCHESTER STRAFFORD
10.METHOD OF DISPOSITION(1.Burial 2.Temp.Entombment 3.Cremation 4.Donation 5.Mausoleum 6.Other): CODE: 1
11.PLACE OF DISPOSITION(Name of cemetery,crematory or other place) PINE VIEW CEMETERY
12.LOCATION (City/Town,State) QUEENSBURY,NY
13.DATE OF DISPOSITION(Refer to 19a) AUGUST 4,2011
14.IF ENTOMBED(OR CREMATED)PLACE OF FINAL BURIAL
15.LOCATION OF FINAL DISPOSITION(City/Town,State)
A CERTIFICATE OF DEATH,HAVING BEEN FILED AS REQUIRED BY THE LAWS OF THS STATE,PERMISSION IS HEREBY GIVEN TO:
16.FUNERAL DIRECTOR DANIEL A SPENCER 17.N.H.LIC.NUM ONLY 902
18.NAME AND LOCATION OF FACILITY(City/Town,State) R M EDGERLY AND SON FUNERAL HOME,ROCHESTER,NH
19.COUNTER SIGNED AGENT(City Board of Heath/Sub-Register if app.) 20.CITY/TOWN 21.DATE ISSUED(Month,Day,Year)
DANIEL A SPENCER ROCHESTER AUGUST 3,2011
CEMETERY OR STORAGE VAULT AUTHORITY SHALL FILL OUT SPACE BELOW WHEN APPLICABLE,
22.IF STORED,BODY WAS PLACED IN(Name of Storage Vault) 23.DATE STORED(Month,Day,Year) 24.CITY/TOWN,STATE
25.SIGNATURE OF SEXTON OR PERSON IN CHARGE OF STORAGE VAULT 26.DATE ISSUED(Month,Day,Year)
CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SPACE;BELOW+ J
27.TYPE OF DISPOSITION(Cremated,buried,etc.) 28.DATE OF DISPOSITION 29.NAME AND LOCATION OF CEMETERY OR VAULT
(Month,Day,Year) (City/Town,State)
Burial 8/4/2011 Pine View Ceretery Queenslcury, NY 12804
30.SECTION 31.GRAVE NO. 32.SIGNATURE OF SEXTON OR PERSON IN CHARGE,
16 Oneida 1 Michael Genier f.
This permit,after being signed by the Sexton or person in charge(or by the Funeral Director where there is no Sexton)must be forwarded within six days to
the clerk of the town in which the disposition takes place.