Stone, Dolores NEW YORK STATE DEPARTMENT OF HEALTH ` # 1Z5
Vital Records Section Burial - Transit Permit
-: Name First Middle Last Sex
• Dolores Mary Stone Female
Date of Death Age If Veteran of U.S. Armed Forces,
' ' 07/31/2018 89 Years War or Dates
Place of Death Hospital, Institution or
-^ City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
7,7 Manner of Death Natural Cause El Accident Homicide Suicide n Undetermined El Pending
1-1 Circumstances Investigation
, ?, Medical Certifier Name Title
Lori Killon PA
Address
170 Warren St,Glens Falls,New York 12801
a Death Certificate Filed District Number Register Number
yt City, Town or Village Glens Fails 5601 367
oDBurial Date Cemetery or Crematory
08/03/2018 Pine View Crematory
IV
❑Entombment Address
, ®Cremation Queensbury Town, New York
R Date Place Remove x
c,.;❑Removal
._. and/or Held
r-- and/or Address
Hold
S Date Point of
Q Transportation Shipment
1 by Common Destination
y"$ Carrier
1Y:Q Disinterment Date Cemetery Address
Q Reinterment
Date Cemetery Address
-41
Permit Issued to Registration Number
£ Name of Funeral Home Maynard D Baker Funeral Home 01130
• Address
41,45 11 Lafayette St,Queensbury,New York 12804
t" Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
i- Address
Permission is hereby granted to dispose of the human remains described above as indicated.
r: Date Issued 08/03/2018 Registrar of Vital Statistics 106eriA Curtis(ECectronica(6Signed)
(signature)
District Number 5601 Place Glens Fails, New York
IA
'`.--");1< I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,• - Date of Disposition $/t, (IQ Place of Disposition F.r�,...,
¢ (address)
(section) (lot nu�'p) (grave number)
Name of Sexton or Person in Charge of Premises ar' `'.i44t
(please priit)
al
z Signature 4
Title ( AAli1;, ��
(over)
DOH-1555 (02/2004)