Shea, Dorothy tr
NEW YORK STATE DEPARTMENT OF HEALTH` ` qsz
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dorothy R. Shea Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/04/2013 96 years War or Dates
1- Place of Death Hospital, Institution or
CityILI , Tommy, Glans Falls Street Address Glens Falls Hospital
• Manner of Death®l$atural Cause 0 Accident 0 Homicide 0 Suicide ❑Undetermined Pending
Mt "'Circumstances Investigation
W Medical Certifier Name Title
William Tedesco M. D.
Address
3 Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City;TowKnYlliMIXXX Glens Falls 5601 333
❑Burial Date Cemetery or Crematory
❑Entombment 08/08/2013 Pine View Crematorium
Address
>; t2Cpemation Queensbury. NY 12804
Date Place Removed
Z Removal and/or Held
2❑and/or Address
H Hold
Cl)
O Date Point of
wLiTransportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01078
Address
136 Main Street South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
Ik Remains are Shipped, If Other than Above
', Address
IX
to
fl'` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/05/2013 Registrar of Vital Statistics LA..3' c2&i'cr .- '
(signature)
District Number 5601 Place Glens Falls t/4)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lU• Date of Disposition S/5(13 Place of Disposition gripiMJ etwc4df tw.
2 (address)
ILEI
CO
1l (section) /I (lot number) /� (grave number)
Name of Sexton or Perso in Charge of P mises r•� J`111
Z (p ase print)
Signature Title atc MAUL
(over)
DOH-1555 (02/2004)