Caldaroni, Donata ll
NEW YORK STATE DEPARTMENT OF HEALTH ` f
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donata Caldaroni Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/2/2018 78 War or Dates
F,, Place of Death Hospital, Institution or
Z City, Town or Village Lake George Street Address 2724 State Rt 9
9,1 Manner of Death C Natural Cause 0 Accident n Homicide E Suicide n Undetermined n Pending
tip Circumstances Investigation
ig Medical Certifier Name Title
0 Suzanne Bergin,MD
Address
Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Lake George 5651
❑Burial Date Cemetery or Crematory
El Entombment December 5,2018 Pine View Crematorium
Address
l Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
O.
❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quake Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to hom
Remains are Shipped, If Other than Above
2 AddressO. Permission is hereby grant d to dispose of the huma ins described abo : as I dicat d.
Date Issued S- Registrar of Vital Statistics tt ka , ; I /
(signature
District Number 5651 Place Lake George
t— I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iti Date of Disposition IZ I L lit Place of Disposition „0,,.. 61ora,.i
2 (address)
Ili
(section) A(lot number) (grave number)
p Name of Sexton or Person in Charge Premises ais �011aa�
`Z (ple4se print)
Signature Title f roid KY I..
(over)
DOH-1555(02/2004)