Haberland, Doris NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit vermit
Name Fir oris Last MiddleMargaret Venner Haberland Sex Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/23/2013 79 years War or Dates
i- Place of Death Hospital, Institution or
W City, TWX9rXitIMX Saratoga Springs Street Address Wesley Health Care Center
W Manner of Death m Natural Cause 0 Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
14 Rick D. Teetz M. D.
Ad dress
131 Lawrence Street, Saratoga Springs N Y
Death Certificate Filed District Number Register Number
City, T W4X9r)V Saratoga Springs 4501 533
❑Burial Date Cemetery or Crematory
12/26/2013 Pine View Crematory
0 Entombment Address
pCremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
0❑and/or
h„ Hold Address
to
0 Date Point of
Q`El Transportation Shipment
C by Common Destination
Carrier
I::Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Springs, NY
Name of Funeral Firm Making Disposition or to Whom
Ii: Remains are Shipped, If Other than Above
;; Address
w
f' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/24/2013 Registrar of Vital Statistics 4--Rr,,,‘ 11, -41/1-airulk
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
til Date of Disposition to-at,-(3 Place of Disposition Zia,,u, C,.i-vtor —.
(address)
Ui
VI
CC (section) gnymber) (grave number)
0
ilk Name of Sexton or Person in C rge of Premi es �a1-0L- t h.49
(pleaseiprint)
44
Signature yL Title Ciic la
(over)
DOH-1555 (02/2004)