Verhagen, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH i O2
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
'::• Dorothy Anita Verhagen Female
rDate of Death Age If Veteran of U.S. Armed Forces,
▪ December 19,2015 88 War or Dates
Place of Death Hospital, Institution or
3 City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death
X Natural Cause 1 'Accident Homicide Suicide Undetermined Pending
a Circumstances Investigation
Medical Certifier Name Title
Dean Reali
Address
• 100 Park Street,Glens Falls,NY 12801
jf Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 60 '
❑Burial Date Cemetery or Crematory
— Entombment December 21, 2015 Pine View Crematorium
Address
0 Cremation Quaker Road, Queensbury,NY 12804 _
Date Place Removed
ZZ,I 'Removal and/or Held
and/or Address
Hold
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0 Date Point of
( Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r Permit Issued to Registration Number
$: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
:.'-'. 53 Quaker Road, Queensbury,NY 12804
: Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
114 Address
itli
Permission is hereby granted to dispose of the human remains described above as indicated.
;r
: ; Date Issued 1 Z f' ' 4� Registrar of Vital Statistics Cd w-� -A
(signature)
;;: District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ww Date of Disposition /2-22-1 5- Place of Disposition /�,n e U,eA,,.J C�em .0,i/
W (address)
CO
tY
(section) (lot number) (grave number)
p Name of Sexton or Perso in Charge of Premises J w/,t,.,.r 44.m-c-/,e
Z (please print)
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Signature Title L reA4o-e--
(over)
DOH-1555(02/2004)