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Kingsley, Dorothy e . # (13Q NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Dorothy Justine Kingsley Female Date of Death Age If Veteran of U.S. Armed Forces, 06/12/2016 93 years War or Dates I- Place of Death Hospital, Institution or Z City, TOWXXr)10X X Glens Falls Street Address 36 Fulton Street 0 Manner of Death Undetermined Pending ,��� ©Natural Cause �Accident �Homicide �Suicide � � Circumstances Investigation til Medical Certifier Name Title CI Eric A. Goe M D Address 65 Elm Street Glens Falls, Ny 12801 Death Certificate Filed District Number Register Number City, TdWCdC& C Glens Falls 5601 301 ❑Burial Date Cemetery or Crematory 06/14/2016 Pine View Crematorium ❑Entombment Address LCremation Queensbury, NY 12804 Date Place Removed Z Removal and/or Held 9.❑and/or Address t Hold CO 0 Date Point of 95❑Transportation Shipment L by Common Destination g. Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan & Denny Funeral Home 10441 Address South Glens Falls, NY iii Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address CC LU 9' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/13/2016 Registrar of Vital Statistics j J CA,.Kv,$) Vj (sign ure) Ei District Number 5601 Place Glens Falls, N' U I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition (([1((6 Place of Disposition ?#.40,,-, a {c- 2 (address) t;/ (section)CC -(lot umber (grave number) 0 Name of Sexton or Person in Charge of Premises di Z (please print)" Signature a Title CrUi tiviThil • (over) DOH-1555 (02/2004)