Durham, Dorothy 11/23/2011 17:21 15134895532 TEBBUT7 f-HtutiRl1_,K --
NEW YORK STATE DEPARTMENT OF HEALTHsic 7
Burial -' Transit Permit
Vital Records Section Z
1 Name First Middle Last fI Sex
Dorothy M. Durham I Female —_
! Date of Death '-Age , If Veteran of U.S,Armed Forces,
i November 26, 2011 ! 75 i War or gates No w
XPlace of Death Hospita, irlatitution
' Cit Town or Villa elli Cit of Albany ; or Street Address Albany Medical Center
Manner of Death Natural Undetermined 7 Pending
' ❑ Accident N❑ Homicide Suicide ❑
Cause � Circumstances Investigation
Medical Certifier Name Title
p Anna Butrymowicz i MD I
Address s
AMCH, 43 New Scotland Ave.,Albany, NY 12208
_
Death Certificate Filed ' District Number I Register Number
City,Town or Village City of Albany 1 101 12188
Date T Cemetery or Crematory
EBurial November 29, 2011 I Pine View Cr rnato
❑ Entombment Address — �. ����- .. _-.w._._ ___aw:m....,I�....._.�
®Cremation
Queensbury, NY
i Date Place Removed
Z1 Removal and/or Held
I Q ❑ and/or Address
1 t"' Hold
O ' Date Point of
a., j Shipment
W' ❑ 8y Common Destination ""
Q'; Carrier .
❑ Disinterment Date 1. Cemetery Address
Date Cemetery Address
0 Reinterment
Permit Issued To Registration Number
Name of Funeral Home_ Regan & Denny Funeral Home 01443
Address µmm
53 Quaker Road, Queensbury, NY 12804
i Name of Funeral Firm Making Disposition or to Whom
• �`'- Remains are Shipped, If Other than Above
I' Address
tPermission Is hereby granted to dispose of the human remains desonjed ab e as Indicated.
Issued November 28, 2011 Registrar of Vital Statistics C 4,_ - f 17
(Signature • f
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of Ii accordance with this permit on:
z Date of Disposition t.l-,19"20 t( Place of Disposition T t'ne rJ e CS wt.c.Cor-�
tat J inn
i (address) .1I (section) (lot number) (grave number)
W I n.
Name of Sexton or Person in Charge of Premises t t eel o`� v„.�1k
_ 'µ(please print) r �"
1 Signature `Q -- Title e-1*.e r►e nify I-cs4 ' �._ j
(over)
DOH-1555 (02/2004)