Holford, Dorothy if 51s
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
•:' Name First Middle Last Sex
Dorothy M. Holford Female
---= Date of Death Age If Veteran of U.S. Armed Forces,
` August 12,2014 85 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Chester Street Address 108 Route 28N
Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
w Circumstances Investigation
s Medical Certifier Name Title
Jennifer Donovan
Address
®Y ]HHHN,Johnsburg,NY 12843
Death Certificate Filed District Number Register Number
City, Town or Village Chester 5652
El Burial Date Cemetery or Crematory
II Entombment August 13,2014 Pine View Crematory
Address
ElCremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
cTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'= u4- Permit Issued to Registration Number
4 Name of Funeral Home Alexander-Baker Funeral Home 00037
gr°a Address
: 3809 Main Street,Warrensburg,NY 12885
No
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
tt
ILI
Permission is hereby granted to dispose of the human r, ai desc i e ye as ndicated.
«°�° Date Issued 8 i/� i 6 Registrar of Vital Statistics � ��/ ! ,
, 1
(signs re)
47.
'AZ'° District Number 5652 Place Chester
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w` Date of Disposition $hS h tj Place of Disposition f ii,,,,, 64vr,._
2 (address)
W
CL (section) (lot num ) (grave number)
pName of Sexton or Person in Charge of Premises kple., y,rr
`Z (please print)
Signature A. Title CiNItga
(over)
DOH-1555 (02/2004)