Horner, Dorothy it
NEW YORK STATE DEPARTMENT OF HEALTH `til
Vital Records Section I ' . 1 Burial - Transit Permit
Name First Middle Last Sex
Dorothy Helen Horner FeMale
Date of Death Age If Veteran of U.S. Armed Forces,
8/2 4/1 2 85 War or Dates No
}•w Place of Death Hospital, Institution or
City, Town or Village Argyletti Street Address PVI Argyle, NY
0 Manner of Death®Natural Cause [i Accident 0 Homicide El Suicide El Undetermined El Pending
Circumstances Investigation
iii Medical Certifier Name Title
Barney Rubenstein MD
Address
35 Gilva Cambridge, NY 12816
Death Certificate Filed District Number Register Number ''\\
City, Town or Village Argyle 6-la3 V
❑Burial Date Cemetery or Crematory
`DEntombment 8/27/12 Pine View Crematory
Address
Cremation Quaker Road, Oueensbury, NY
Date Place Removed
9❑Removal and/or Held
and/or Address
F= Hold
10
0 Date Point of
ti
to Q Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Khmer Funeral Home 01077
Address
is 123 Main St. Argyle, NY 12809
Name of Funeral Firm Making Disposition or to Whom
*4 Remains are Shipped, If Other than Above
• Address
tr
111
CL
Permission is hereby granted to dispose of the human e ains descr ed above as indicated.
Date Issued 8/27/12 Registrar of Vital Statistics Lift l/V
(signature)
District Number5956 Place Town of Argyle, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU• Date of Disposition 1-7,WW'i1 Place of Disposition p„,,ui,, 6.410 f vi.
2 (address)
ttU
CO
CC (section) A (lot numb) (grave number)
Name of Sexton or Person in Charge of Premises L bray., efti.. '1'
Z (please print)
41 Signature '' Title 01.101°i'VL
(over)
DOH-1555 (02/2004)