Spencer, Marjory 4t-414410 I',
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section t; _ )1 Burial - Transit Permit
Name First Middle Last Sex
Marjory A. Spencer Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/12/2012 78 years War or Dates
}- Place of Death Hospital, Institution or
Z City, 1XxXOPX9181Ect Saratoga Springs Street Address Wesley Health Care Center
mManner of Death 0 Natural Cause 0 Accident El Homicide 0 Suicide Undetermined 11 Pending
ttil Circumstances Investigation
lit Medical Certifier Name Title
0 Rick D. Teetz M. D.
Address
131 Lawrence Street, Saratoga Springs N Y
Death Certificate Filed District Number Register Number
City, "DOOTADOMItigt Saratoga Springs 4501 114
❑Burial Date . Cemetery or Crematory
03/13/2012 Pineview Crematorium
>i>[]Entombment Address
• .I,!,,;,JCremation Queensbury N Y
Date Place Removed
Removal • and/or Held
p a
p and/Holdor Address
O Date Point of
t1 Transportation Shipment •
G" by Common Destination .
Carrier
El Disinterment Date Cemetery Address
ReintermentIIRE Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
<` Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;'; Address
lit
Permission is hereby granted to dispose of the human rema' cri d ably indicat .
iiiiii Date Issued 03/12/2012 Registrar of Vital Statistics
(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
ILI Date of Disposition a11M At Place of Disposition F.0.V4.4%.4 Cekn,, crli"..,
(address)
W
VI
CC (section) (lot number) (grave number)
• Name of Sexton or Pe on in Charge f Premises4,,,,c,„14,,-- C JQyr,�
I (please print)
lit Signature L J' L_ Title OlnoA-TOL
(over)
DOH-1555 (02/2004)