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Golden, Delores NEW YORK STATE DEPARTMENT OF HEALTH it 4/ Vital Records Section Burial - Transit Permit Name Firstelores MiddleM Golden Sex Date of Death Age If Veteran of U.S. Armed Forces, 08/19/2015 68 years War or Dates }- Place of Death Hospital, Institution or 6 City, Td(Xr MN( Glens Falls Street Address Glens Falls Hospital WManner of Death Natural Cause ElAccident ❑Homicide ❑Suicide 0 Undetermined ❑Pending U Circumstances Investigation ill Medical Certifier Name Title Pamela F. Lusignan ANP Address luark Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Tegr Mfagei Glens Falls 5601 415 ❑Burial Date Cemetery or Crematory 08/24/2015 Pine View Cemetery ['Entombment Address ©Cremation Ouecnsbury, NY 12804 Date Place Removed Z Removal and/or Held 2❑and/or Address In Hold O Date Point of Transportation Shipment in by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home, Inc. 00448 Address 7 Sherman Ave. Corinth, NY 12822 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address I lily Permission is hereby granted to dispose of the human remains descryed abov as ' icated. Ei Date Issued 08/21/2015 Registrar of Vital Statistics 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: ill .Date of Disposition $i III Place of Disposition /spy s./ C,� 2 (address) LEE 'II I (section) A Lot number),' (grave number) Name of Sexton or Person in Charge of Premises Art ` 31Awd - Z ( ease print) • Signature Title /kb-ifi it (over) DOH-1555 (02/2004)