Caverly, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
J Name First Middle Last Sex
Dorothy Mae Caverly Female
rr ti.* Date of Death Age If Veteran of U.S. Armed Forces,
�:: March 13, 2015 87 War or Dates
..r1 Place of Death 1•
Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Phillip J.Gara Dr.
Address
▪ :;327 Broadway,Fort Edward,NY 12828
:.::. Death Certificate Filed District Number Register N mber
City, Town or Village Fort Edward 5657 pZ
❑X Burial Date Cemetery or Crematory
March 18, 2015 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
H Hold
Cl)
O Date Point of
wTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:tir Permit Issued to Registration Number
:rr Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
•::r; 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i;; Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r ains_describ ab v as indicated.
:: Date Issued ,3 I(p [% Registrar of Vital Statistics ,
I
:r; (signature)
• j District Number 5657 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 3/1 8/201 'lace of Disposition 21 Quaker Road, Queensbury, NY 1 2804
W (address)
M Mohican 12C 1
W (section) (lot number) (grave number)
pName of Se ton or Person in Charge of remises Connie L. Goedert
Z (please print)
W Signature pu-L ` Title Cemetery Superintendent
(over)
DOH-1555(02/2004)