Reith, Dolores WO
NEW YORK STATE DEPARTMENT OF HEALi Burial - Transit Permit
Vital Records Section
f Name First Middle Last Sex
Dolores L Reith Female
Date of Death Age If Veteran of U.S. Armed Forces,
''':rr September 22, 2015 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Scott Biasetti Dr
r• Address
r f, 100 Park St.,Glens Falls,NY 12801
',, Death Certificate Filed District Number Register umber
: City, Town or Village Glens Falls 5601 . )
❑Burial Date Cemetery or Crematory
II Entombment September 23,2015 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F_- Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
"al Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
▪ Address
53 Quaker Road, Queensbury,NY 12804 •
�ij: 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.
▪ Date Issued 'I ( 2'3 ) 15 Registrar of Vital Statistics U\)CA.A.4-14
(signature
•• ikSt
6• District Number 5 bc ) Place `f7/1/\-S Fo, \A,5 4)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition CfI15116- Place of Disposition ,{;a0..,i Cr440r�.
W (address)
N
O (section) /� ,(lot number. (grave number)
el• Name of Sexton or Person in Charge of Premises VIA.di .fit ff
Z ( lease print)
W
•
Signature Title -4"I 'L
(over)
DOH-1555(02/2004)