Dillenbeck, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH V .
EY
Vital Records Section Burial - Transit Pertnit
Name First Middle Last Sex
Dorothy Dillenbeck Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 19, 2015 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death X❑ Natural Cause El Accident ❑ Homicide Suicide ❑ Undetermined 1-1❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Eileen Spinelli,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number�..).55 Reel(�1 Number
City, Town or Village Fort Edward
❑Burial Date Cemetery or Crematory
September 21, 2015 Pine View Crematory
❑Entombment Address
k ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
., ❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is here y granted to dispose of the human ,:inadescr'be• abo as indicated.
Date Issued��� (� Registrar of Vital Statistics d�� _ I% ,:
(signature)
District Number C l6 5 Place I (fu}-A._ -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/21/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) / (lot number) (grave number)
Name of Sexton or Pers n in Char, a of Premises9 �t a o Si°"4t
( ease print) �Signature C-�+� TitleatOM�
(over)
DOH-1555 (02/2004)