Stein, Delores NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle - Last Sex
Delores M.Stein Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/13/2018 79 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Troy Street Address Samaritan Hospital
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Adrian Karatnycky MD
Address
2215 Burdett Ave,Troy,New York 12180
Death Certificate Filed District Number Register Number
City, Town or Village Troy 4102 429
❑Burial Date Cemetery or Crematory
08/20/2018 Pine View Crematory
El Entombment Address
®Cremation Queensbury, New York
Date Place Removed
El Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 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 described above as indicated.
Date Issued 08/15/2018 Registrar of Vital Statistics 7featherLynn Mufinio(Efectronicaffy Signed)
(signature)
District Number 4102 Place Troy, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Dispositiong-�:i-1' Place of Disposition p;nc v;C.w GPc,r,,,kry
(address)
(section)s (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Tr.("CY f�S
(please print)
J
Signature �/r. • Title C,FC-n"itt`'r
(over)
DOH-1555(02/2004)