VanDyck, Caroline # Zs-)
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
,
• Name First Middle Last Sex
Caroline K. VanDyck 1 Female
Date of Death Age If Veteran of U.S. Armed Forces,
• May 13, 2012 85 War or Dates No
Place of Death Hospital, Institution or
ig City, Town or Village Glens Falls Street Address Glens Falls Hospital
1s Manner of Death I XI Natural Cause I I Accident n Homicide n Suicide Undetermined Pending
Circumstances Investigation
tij Medical Certifier Name Title
0 Christopher D.Hoy Dr.
Address
102 Park St,Glens Falls,NY 12801
al Death Certificate Filed 1 District Number Register Number
City, Town or Village Glens Falls 5601 ia2a7r
❑Burial Date Cemetery or Crematory
❑Entombment May 21,2012 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
�' Hold
N
0 Date Point of
fk n Transportation Shipment
a by Common Destination
Carrier
7 Disinterment Date Cemetery Address
n Reinterment Date . Cemetery Address
°r s Permit Issued to Registration Number
:i :: Name of Funeral Home Regan & Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
:3o Name of Funeral Firm Making Disposition or to Whom
IM Remains are Shipped, If Other than Above
El Address
CC
• Permission is hereby granted to dispose of the human remains descri ed above as i c ted.
Date Issued O/(;,, 20/Z Registrar of Vital Statistics
signal re)
yeas District Number 5601 Place Glens Falls //i� A �a
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1-Ill 1 it Place of Disposition �V VW) col 01�
2 (address)
W
N
Qre (section) Akik--/Lr(lot number) S (grave number)
Name of Sexton or Pers n in Charge o Premises Z l
(please print)
W Signature Title CAM grOyi
(over)
DOH-1555(02/2004)