Heidorf, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH r # 4 t(a.
Vital Records Section gII, Burial - Transit Permit
Name First Middle Last Sex
Dorothy Louise Heidorf Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 1, 2014 88 War or Dates
I3 Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death J Natural Cause 0 Accident 0 Homicide ID Suicide riUndetermined ri Pending
0 Circumstances Investigation
W Medical Certifier Name Title
CI Joseph Foote MD, _
Address
Rt 4 Hudson Falls, NY 12839
Death Certificate Filed District Number Register Nyober
City, Town or Village tt�'//
❑Burial Date Cemetery or Crematory
July 3, 2014 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date . Place Removed
0- Removal and/or and/or Held
Address
F. Hold
N Date Point of
11, ❑Transportation Shipment
by Common Destination
8 Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
F_- Remains are Shipped, If Other than Above
2 Address
W
f}" Permission is herebygranted to dispose of the human remains descb d abb ve I i a ed.
Date Issued 07 zp/y Registrar of Vital Statistics % /� G
i nature
5 (.v�v �'District Number O/ Place ``S �, A (S)6
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ly-
W Date of Disposition 07/03/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
WIX CO
(section) (lot numbe (grave number)
0 Name of Sexton or Person in Charge of Premises r f ,tyin4�
� ( lease print)
W Signaturetfid % Title CI1rit4/1162
(over)
DOH-1555 (02/2004)