Dallek, Alice 3
f
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
::3:: Name First Middle Last Sex
::o Alice Dallek Female
tir
;;r; Date of Death Age If Veteran of U.S. Armed Forces,
rf:;r April 21,2015 92 War or Dates
Place of Death 1r
Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
: David Cunningham
Address
::;3 Irongate Center, Glens Falls,NY 12801
▪ Death Certificate Filed District Number Register Number
;▪::r City, Town or Village Glens Falls 5601 Z/e
❑X Burial Date Cemetery or Crematory
April 24, 2015 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
F' Hold
0 I Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
1
: Permit Issued to Registration Number
;ti Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
:;: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:: : Permission is hereby granted to dispose of the human remains descriped a ov as i icated.
::: Date Issued / g 42‘ i'
; :
Q y 1L/.3� Registrar of Vital Statistics tt
(signature)
:? District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
uiDate of Disposition 4/2 4/2 01 5 Place of Disposition 2 1 Quaker goad, Qie ss}uiry my 17804
adw Mohawk 78A ( ) 1
to
CL (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises Connie L. Goedert
Z (please print)
w Signatur K 111--e_ t p� - Cc? Yy Title Cemetery Superintendent
(over)
DOH-1555(02/2004)