Younger, Dolores IT(46NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last t� n�ec Sex
Dolores B. -�Fuu+�y , "Itu Female
`. _ Date of Death Age If Veteran of U.S. Armed Forces,
06 / 07 / 2017 88 War or Dates N/A
}-' Place of Death Hospital, Institution or
City, Town or Village Wilton Street Address 10 Lonesome Pine Trail
g Manner of Death®Natural Cause E Accident D Homicide E Suicide — Undetermined �Pending
Circumstances Investigation
at Medical Certifier Name Title
Richard L Farrell Jr. MD
Address
15 Maple Dell, Saratoga Springs, NY 12866
>' Death Certificate Filed District Number $/ `�l`�(0q Register Number
City, Town or Village Wilton
:siiLIBurial Date //- ,/ 7 Cemetery or Crematory
(P / / / Zul Pine View Crematory
E `u Entombment Address
Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
W. Date Point of
Transportation Shipment
by Common Destination
Carrier
liiiii
Q Disinterment Date Cemetery Address
Ui IN
0 Reinterment Date Cemetery Address
W Permit Issued to Registration Number
» Name of Funeral Home Compassionate Funeral Care 00364
Address
11 402 Maple Ave., Saratoga Sp., NY 12866
iliai Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ft
Lifi
"` Permission< l GL
is hereb granted to dispose of the human rema'ns described abo a as indicated.
' Date Issued (p 7 f 1 Registrar of Vital Statistics /t 6 0C(._O '
' (signature)
im
Mi District Number if5la t Place Wilton , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
VA Date of Disposition bill(1 Place of Disposition ,u t,,,, r!' 'forh-
(address)
111
ir (section) / (lot number) (grave number)
42 Name of Sexton or Person in Charge of Premises Llgr.s L— tvftt7
Z n, (phase print) •
Signature G{ /I Title M4121/U
(over)
DOH-1555 (02/2004)