Anderson, Dorothy sL�NEW YORK STATE DEPARTMENT OF HEALTH . -
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
iii Dorothy P. Anderson Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 21, 2012 89 War or Dates
▪ Place of Death Hospital, Institution or
• City, Town or Village Ft. Edward Street Address Ft. Hudson Nursing Home
cs, Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W. Circumstances Investigation
Medical Certifier Name Title
•, Daniel Larson,MD
Address
9 Carey Rd.Queensbury,NY
:• a' Death Certificate Filed District Number Registe Number
i
Cty, Town or Village Ft.Edward 14=114.3?
❑Burial Date Cemetery or Crematory
❑Entombment October 25, 2012 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
1::: Hold
N
O Date Point of
35 n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
.: Permit Issued to Registration Number
::: Name of Funeral Home Regan& Denny Stafford Funeral Home 01443
:n Address
53 Quaker Road, Queensbury,NY 12804
;, Name of Funeral Firm Making Disposition or to Whom
M Remains are Shipped, If Other than Above
N Address
re
bit
: Permission is he by gr nted to dispose of the human as described abo as indicated.
Date Issued/o /� in
Registrar of Vital Statisti
(signature)
District Number NY-054321 Place Ft.Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition to-(b-0., Place of Disposition ,,cUL) Co ora„_
W (address)
co
O (section) � • (lot number) (grave number)
pName of Sexton or Person in Charge of Premises t h rid �qal-
W (please print)
Signatureg491--- J_......._ Title Ci2 L d ai.
(over)
DOH-1555(02/2004)