Claydon, Dylia L. NEW YORK STATE qE= RTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital k`'6r` ,`
Name First; ,]`` Middle Last Sex
Dylia L Claycle':,' Female
Date of Deatf Age If Veteran of U.S.Armed Forces,
02/14l2020 92 Years War or Dates
I.— Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
p Manner of Death nicNatural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Brittany Miske NP
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 102
Burial Date Cemetery,Crematory or Facility Name
02/15/2020 Pineview Crematory
Entombment Address
Cremation Queensbury,New York
Donation
z Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
0• Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
10 Reinterment Date Cemetery Address
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
IZ
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/14/2020 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 —/j-ZpLU Place of Disposition Poe /-wry r
W I sl
2
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(n (section) (lot numb (grave number)
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0 Name of Sexton or Person in Charge of PremisAYfN
Z (please print)
W Signature Title �F
DOH-1555(o7/18)p 1 of 2
t
Public Health Law Sec. 4145(2b) 0 3 3
Receipt
Human remains of , delivered on , 20
1"
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#