DeLor, Emma May NEW YORKSTATE DEPARTMENT OF HEALTH s 1 I
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Emma May DeLor Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/13/2020 100 Years War or Dates
iI.- Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
`p Manner of Death Natural Cause Accident ❑Homicide ❑Suicide Undetermined ❑Pending
0 Circumstances Investigation
WW Medical Certifier Name Title
Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 6
Burial Date Cemetery,Crematory or Facility Name
01/13/2020 PineView Crematorium
Entombment Address
FRICremation Queensbury Town, New York
❑Donation
zRemoval Date Place Removed
and/or and/or Held
~ Hold Address
N
O
d Date Point of
to ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
JEJReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann, New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/13/2020 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ,
Z Date of Disposition Iq 170 Place of Disposition t k ZAIrN
W
2 (address)
W
N (section) 110tnumber) (grave number)
GName of Sexton or Person in Charge of Premises �v 1
Z (ple a print)
W Signature ZY Title 6n►
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) n 013?3 5)
Receipt
Human remains of !)J. ,�� r_ delivered on
r'
f
Pine View Cemetery Representing the funeral home namedpn bur�}ai permit
Official Funeral Directors Reg.or License: