Kingsley,Florence M. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Florence M Kingsley I Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/26/2020 100 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs --TStreet Address Saratoga Hospital
w Manner of Death Undetermined Pending
0 �Natural Cause �Accident �Homicide �Suicide
W Circumstances Investigation
W Medical Certifier Name Title
0 Todd Duthaler DO
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 56
Burial Date Cemetery,Crematory or Facility Name
01/29/2020 Pineview Crematory
Entombment Address
0 Cremation Queeensbury Town,New York
ElDonation
z ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
(L Date Point of
En Transportation Shipment
Q by Ammon
arti Cer Destination
Disinterment Date Cemetery Address
Reinterme t Date Cemetery Address
n
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
uJ
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/28/2020 Registrar of Vital Statistics John Paul Franck(Electronically Signed)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 79 t ZV Place of Disposition �u�4✓ rk'—
W (address)
2
W
N (section) (iot number) (grave number)
Q
Name of Sexton or Person in Charge of Premises ��
0 please print) firw�,l JD&
Z
W Signature Title
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013268
Receipt
j�-
Human remains of r delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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