Burlingame, MIldred NEW YORK STATE DEPARTMENT OF HEALTHZ'
Vital Records Section Burial - Transit Permit
•
Name First Middle Last Sex
Mildred Sharon Burlingame Male
Date of Death Age I If Veteran of U.S. Armed Forces,
0b/ 28 / 2015 56 War or Dates N/A
} - Place of Death Hospital, Institution or
City, Town or Village Schuylerville Street Address 32 Burgoyne St.
tija Manner of Death®Natural Cause E Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
ta Medical Certifier Name Title
0 John Mongan MD
Address
6 Medical Park Dr. , Ste 200, Malta, NY 12020
Death Certificate Filed District Number Register Number
City, Town or Village Schuylerville
< Burial Date Cemetery or Crematory
08 / 31 / 2015 Pine View Crematory
=''fEntombment Address
Cremation 21 Quaker Road, Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Ei Hold
5 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
iiiiii
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
iN Address
di 402 Maple Ave., Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
iii
"` Permission is hereby granted to dispose of the human rem . described above as indicated.
Date Issued D« Registrar of Vital Statistics _ £ /D i, pA,_
(signs)
District Number 445-as Place Schuylerville , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
10 Date of Disposition gitli r Place of Disposition ; C Attf'o
(address)
Ui
Ill
ir (section) 4 (lot number) ( (grave number)
eltt
ci Name of Sexton or Person in Charge of Premises '4 L-+�"`
(please print)
:., Signature d Title ol0'" A--
(over)
DOH-1555 (02/2004)