Dodge, Carol NEW YORK STATE DEPARTMENT OF HEALTH it 4e5t1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carol L. Dodge Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/29/2016 63 years War or Dates
Ii- Place of Death Hospital, Institution or
5 City, To X*OM Saratoga Springs Street Address I/IRry's Hiven 35 NPw Street
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
I E Circumstances Investigation
ILI Medical Certifier Name Title
Cr George Siniaphin M D
Address
604 Palmer Ave Corinth N Y
Death Certificate Filed District Number Register Number
City, Tmmo(*mot Saratoga Springs 4501 559
s ❑Burial Date Cemetery or Crematory
['Entombment11/30/2016 Pineview Crematory
Address
[,Cremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
9❑and/or
Address
Hold
11/
0 Date Point of
❑Transportation Shipment
5 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑ Date Cemetery Address
Reinterment
:< 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
# Remains are Shipped, If Other than Above
Address
I
tit
IL.] Permission is hereby granted to dispose of the human remains c ' ec bovreps' icated.
Date Issued 11/29/2016 Registrar of Vital Statistics ,�►�jr["_�_ �
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ,1
IW Date of Disposition ,L 11 J/k, Place of Disposition �nttL 6,
(address)
Ui
cc (section) 11(lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises ` L44 r Si^Alit
(pie se print)
Signature
e1 •,-Ir. Title ClieMetilit
(over)
DOH-1555 (02/2004)