Dallis, Doroty NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mid12Ie Last Sex
Dorothy E.C. Dallis Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/22/2015 95 years War or Dates
f- Place of Death Hospital, Institution or
Z City, T Street Address
Ili �C Saratoga rings Sara Hospital
0 M nnerr o eat�Natural Cause Accident ❑Homicide ❑Suicide Undetermined ❑Pending
IL Circumstances Investigation
1,Li Medical Certifier Name Title
L Address ikheil Mavashev M.D.
Death Certificate Filed District Number Register Number
City, T00 y'4C Saratoga Springs 4501 143
❑Burial Date Cemetery or Crematory
❑Entombment Address 03/23/2015 Pi.np View Crematorium
QCremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
2 and/or Address
Cf)
n- Hold
0 Date Point of
rL Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Care, Inc. 00364
Address
402 Maple Avenue�aratoga Spr�_ingc, N Y 12866
Name of Funeral Firm Making Disposition or to Whom
}- Remains are Shipped, If Other than Above
Address
tt<
1LI
117 Permission is hereby granted to dispose of the human remains 'be abov " icated.
Date Issued 03/23/2015 Registrar of Vital Statistics
(signature)
District Number Place
11501 Saratoga Springs
-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z � /
l `Date of Disposition -�j%rPlace of Disposition all k di,e--- (11/Z4n Y
2 (address)
Il
ID
CC (section) � lt nun' er) (grave number)
Name of Sexton or " Charge of Premises �' ` i
Z (pleas print)
/1
Signature ��? Title CiiW �`
(over)
DOH-1555 (02/2004)