Fullerton, Dorothy 0Y
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dorothy D. Fullerton Female
Date of Death Age 93 If Veteran of U.S. Armed Forces,
n March 25, 2012 War or Dates
E_: Place of Death Hospital, Institution or
Z. City, Town or Village North Creek Street Address Tri-County
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined I ' ,nding
tit, Circumstances nvestigation
' Medical Certifier Name {G� 1iL
Title
Address r
D
/ S J/S
::: Death Certificate File District N er Regist€ imber
City, o • or Village j� c j 56755 9
❑Burial Date Cemetery or Crematory
March 28, 2012 Pine View Crematory
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
U)
0 Date Point of
U) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
b: Name of Funeral Firm Making Disposition or to Whom
ak*: Remains are Shipped, If Other than Above
5, Address
CZ
US
Et Permission is hereby granted to dispose of the human rem 'ns describ abb as indicated.
Date Issued 3I a ?o(a Registrar of Vital Statistics (/V C- `I
(signature)
District Number \�b j�` Place /(7 v "r J i l n S bU
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W II-
Date of Disposition 3-iCl-1Z Place of Disposition e4-1/ikkJ ff,,---
2 (address)
W
(1)
0 (section) (lot number) s7. (grave number)
QName of Sexton or Person in Charge of P emises (1,r� r t,�(�
(p ease print)
uJ �-4�
Signature V Title Ci'N=n1 th)
(over)
DOH-1555(02/2004)