Warner, Dorcas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
.'0,.. Name First Middle Last Sex
r ; Dorcas M Warner Female
jrJ Date of Death Age If Veteran of U.S. Armed Forces,
January 21, 2016 84 War or Dates
Place of Death i
rHospital, Institution or
City, Town or Village Queensbury Street Address The Warren Center
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof Dr.
� � Address
142 Gurne Lane, 1 ueensbu ,NY 12804
Death Certificate Filed District Number Rester Number
s City, Town or Village Queensbury 5657 `',I
❑Burial Date Cemetery or Crematory
January 25, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ piRemoval and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
::::: Permit Issued to Registration Number
1::li Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
' ;: Name of Funeral Firm Making Disposition or to Whom
I': Remains are Shipped, If Other than Above
: Address
:::; Permission is hereby granted to dispose of the human remains described above as indicated.
:; Date Issued; ( l -11C.9 Registrar of Vital Statistics __ aC� ICI S(Z _c
_: (signature)
;:
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1/Zb µ 1p lib Place of Disposition ,r,i (14...ator,.,-_
2 (address)
W
CO
CL (section) ?i (lot number) (grave number)
pp Name of Sexton or Person in Cha ge of Premises f 4 t„tv a ivati-
Z ( ease print
W el
Signature (rI, NOT Title fik fillitL
(over)
DOH-1555(02/2004)