Dickey, Bonnie NEW YORK STATE DEPARTMENT OF HEALTH f ' ' if 6( O
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bonnie Jeanne Dickey Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 15, 2016 71 War or Dates
Place of Death Hospital, Institution or
II City, Town or Village Glens Falls Street Address Glens Falls Hospital
w Manner of Deathifj Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number ll Register Number'7 7CU. /,,
City, Town or Village % !
�� :'❑Burial Date Cemetery or Crematory
September 19, 2016 Pine View Crematorium
e, - ❑Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
0 and/or Address
Hold
0 Date Point of
❑Transportation Shipment
0) by Common Destination
0 Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
F= Remains are Shipped, If Other than Above
Address
Ir
W.,
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9119 f i h Registrar of Vital Statistics 0 ./•1.J\r\i
(signature)
District Number 560( Place 6 Cs�s k\S ,1J y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ili,' Date of Disposition 09/19/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
CO (section) (lot numb(e'r) (grave number)
inName of Sexton or Person in Charge of Premises 4;i744,- st,tsr
z /! (please print)
Signature t Title CeErtA-TO .-
(over)
DOH-1555 (02/2004)