Burckley, Ida NEW YORK STATE DEPARTMENT OF HEALTH 1
Vital Records Section , , 4, Burial - Transit Permit
Name First Middle Last Sex
Ida R. Burckley Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/08/2011 84 years War or Dates
N.- Place of Death Hospital, Institution or
Z 'City, TONCXX X Saratoga Springs Street Address Marys Haven, 35 New Street
0 Manner of Death DNatural Cause O Accident O Homicide O Suicide ri O Undetermined O Pending
W Circumstances Investigation
W Medical Certifier Name Title
C George Jollly M D
Address
One West Ave Saratoga Springs
Death Certificate Filed District Number Register Number
City, ToVAXX AltditAX Saratoga Springs 4501 359
OBurial Date Cemetery or Crematory
08/09/2011 Pineview Crematorium
`:OEntombment Address
[Cremation Queensbury N Y
Date Place Removed
Z❑Removal and/or Held
and/or Address
t Hold
U
0 Date Point of
fi
iit)Q Transportation Shipment
ct by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
!r Remains are Shipped, If Other than Above
Z Address
CC
Ili
P` Permission is hereby granted to dispose of the human remai ib ab 'ndicate
Date Issued 08/08/2011 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were dispgo—
sed of in accordance with this permit on:
at Date of Disposition P,-tt-aPlace of Disposition i ldata...) Crip.4 t7sf tto --
2 (address)
la
Ea
CC (section) r (lot number (grave number)
its Name of Sexton or Per on in Charge of remises At v� r a,..itt
i� L (please print)
l Signature Title COT:01vsi-Z.t)
(over)
DOH-1555 (02/2004)