Hamilton, Dolores t # SY (
NEW YORK STATE DEPARTMENT OF HEALTH `
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nii
Dolores A. Hamilton Female
Date of Death Age If Veteran of U.S. Armed Forces,
: July 10, 2017 `87 t, War or Dates
iii Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ( (Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
11 Medical Certifier Name Title
a. Suzanne Blood,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Num er
pt ' City, Town or Village Glens Falls 5601 3 % 3
❑Burial Date Cemetery or Crematory
❑Entombment July 12, 2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ( (Removal and/or Held
and/or Address
F- Hold
U)
0 Date Point of
EL
cn ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
rE Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
• Permission is hereby granted to dispose of the human remains described above as indicated.
III Date Issued 7 i 4 312 0(7 Registrar of Vital Statistics L JQ&&p . . \./- e .1!
(signat '-)
RR District Number 5601 Place Glens Falls;N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
g Date of Disposition 1 113 r f Place of Disposition fi'mIL,- ahiact,te.
W (address)
N
re
0 (section) (lot
Q of number) (grave number)
Q Name of Sexton or Person in Charge of Premises
t l+r Sc44t(t
W �/ (p�ase print
Signature C jb Title Lek,ft?�
(over)
DOH-1555(02/2004)