Dougner, Sylvia NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First - Middle ast I Sex
Date of Deat I Age Q If Veteran of U.S. Armed Forces,
S LS I -c is' i _(,. War or Dates
ja Place of Death I Hospital, Institution or
City. Town or Village ,cky5%v `1 1 Street Address 7 I S vr-_,►,,,s t D C 45 r
,to of Death Natural Cause Accident Homicide 0 Suicide E Undetermined C Pending
W Circumstances Investigation
Medical Certifier Name Title
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Address 1,7 r.. rr
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Death C cate Filed �trriict NNu er / I Re ister Number
1 Cit oww Village vEL�S RUtZ`'t i
Date { Cemetery`or�Crematory
NBurial 5- /aOIs p tN c \J rc_,J ( Q AiO `I
Address
>: l Cremation} v qt(-Z IL_ 7 l v t, C_iJ 3 v t- lam-- `l ( a O(-f-
Date i Place Removed
Z —Removal I and/or Held
p'
O —and/or Address
Hold
0
O Date Point of
n Transportation I Shipment
fl by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
—
>s Permit Issued to j / I Registration Number
Name of Funeral Home _ S .-c:1-1 ..,;��;,: . /.A., I 01 13Q
Address /
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Name of Funeral Fit�m Making Disposition or to Whom
'w Remains are Shipped. If Other than Above `�
aAddress
Permission is here y granted to dispose of the human e ains described ab ye as indicated.
Date Issued) (-0 1 c' Registrar of Vital Statistics Cyft--t-r...._
c(signat )
` District Number Place 1 O __._r_6 Q-6--,S)D
I certify that the remains of the decedent identified above were disposed of in accordance this permit on:
WDate of Disposition 5/7/201 5Place of Disposition Pine View Cemetery, Quaker Road, Queensbury
2 (address)
11Jtf) New Hudson 13A, Sec. 2 2
N
CC (sectiion) ber} (grave number)
nName of Se , n or Person in Charge of Pr ises onnie L. Go(llodt ernum
Z (please print)
W Signature /2�. .Zca Title Cemetery Superintendent
(over)
DOH-1555 (9/98)