O'Rourke, Dorothy t '
NEW YORK STATE DEPARTMENT OF HEALTH it
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Dorothy H. O'Rourke Female
'f.'; Date of Death Age If Veteran of U.S. Armed Forces,
:7:.,: October 6,2015 98 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death IXI Natural Cause Accident I I Homicide [ Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r, Wendy Steinhacker
Address
�r 10 Park Street Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
4., City, Town or Village 5 Go j Li q O
❑Burial Date Cemetery or Crematory
El Entombment October 7, 2015 Pine View Crematorium
Address
Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I !Removal and/or Held
and/or Address
F Hold
N
O Date Point of
yI 1 Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
f Permit Issued to Registration Number
j s; 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
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
I._: s
s: Date Issued/6 40AI- Registrar of Vital Statistics ��
r�,
r. (signature)
District Number Place Lv/ems.fIts, /// / j
1
}_ I certify that the remains of the decedent identified above were disposed of in accordance� with this permit on:
Z p /0� Disposition 'f m, Lei
W Date of Disposition g�/s Place of i c,� or„ti..
W (address)
N
W (section) (lot numb (grave number)
ca• Name of Sexton or Person in Cha a of Premises Rr'jLrN#4.-
Z (please print)
W
Signature Title lh&_ it
(over)
DOH-1555(02/2004)