Dougherty, Harriet fk l ib0
NEW YORK STATE DEPARTMENT OF HEALTH ` It Burial _ Transit Permit
Vital Records Section ‘
LLa Name First Middle Last Sex
Harriet E. Dougherty Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 17, 2011 93 War or Dates
Z• Place of Death Hospital, Institution or
, City, Town or Village Schuylerville Street Address Stanton Nursing & Rehab Centre
Manner of Death i AI Natural Cause Accident I 'Homicide Suicide Undetermined Pending
yi Circumstances Investigation
Z Medical Certifier Name Title
p. Roslyn Socolof MD
Address
Sherman Ave.Queensbury,NY
Death Certificate Filed D .Fict Rnst Number
City, Town or Village Queensbury S
❑Burial Date Cemetery or Crematory
September 19, 2011 1 Pine View Crematorium
Entombment Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
O I !Removal and/or Held
and/or
F= Hold Address
U5
O Date Point of
N I I Transportation Shipment
G by Common Destination
Carrier
I-1 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' Permit Issued to Regan& Denny Funeral Home Registratio6ber
Name of Funeral Home
ok
03 veusiker Road,Queensbury,NY 12804
,• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
Permission is hereby granted to dispose of the human remains described fbove as indicated.
Date Issued (a-o 1 cC O Registrar of Vital Statistics \Gam_ � .( 9_._,tip.
l
(signature)
' District Numberc-(c) Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition 111:lit Place of Disposition 471140 kw C .'font.&cc
W (address)
CO
0 (section) /� _ (lot numbe (grave number)
ap Name of Sexton or Pers in Charge o Premises L/�,t,9 r g.r0 -
71 (please print)
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Signature Title CQ<PI 0a
(over)
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