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Darrah, Dolores NEW YORK STATE DEPARTMENT OF HEALTH / 0 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Dolores Jane Darrah Female Date of Death Age If Veteran of U.S. Armed Forces, November 14, 2016 67 War or Dates Place of Death Hospital, Institution or l.t` City, Town or Village Glens Falls Street Address Glens Falls Hospital in Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation L Medical Certifier Name Title Dean Reali, M.D Address Hudson Headwaters Warrensburg, NY 12885 Death Certificate Filed District Number 56 Register Numb r Ci ®ty, Town or Village / J ❑Burial Date Cemetery or Crematory November 16, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address i_ Hold } Date Point of pC Transportation Shipment CO by Common Destination C1 Carrier Date Cemetery Address ❑ Disinterment ❑ Renterment Date Cemetery Address Permit Issued to 's 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 H Remains are Shipped, If Other than Above Address ilr tl,i, '- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued t t f t5 / { 6 Registrar of Vital Statistics W l Q- (signature) District Number 5 6o i Place C (QiY\5 \ (\ S ,N I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 11/16/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) W, 0) re. (section) (lot number) (grave number) -. Name of Sexton or Person in Charge of Premises Ga^y tn1 ;e—, b,.. 3 ,r 141 (please print) Signature ;�;...,. h/ . Title e"``-v-^.N T G-/- (over) DOH-1555 (02/2004)