Solberg, Mildred NEW YORK STATE DEPARTMENT OF HEALTI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mildred L. Solberg Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 8, 2012 93 War or Dates
�....: Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address The Pines At Glens Falls
Ili
O Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined Pending
Ili Circumstances Investigation
w Medical Certifier Name Title
E , Suzanne Rayeski,MD
Address
33` 170 Warren Street,Glens Falls,NY 12801
, . 1Death Certificate Filed District Number Regigter Number
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Cremator;
April 11, 2012 Pine View Crematori n
❑Entombment Address
❑x Cremation 21Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
F- Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
.°, Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
`, Address ,
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
5' Address
IYa
Ili
.. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued & ( i 1 ' (2 Registrar of Vital Statistics (.10 CK.A41 4)
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition (.l /1%1IZ Place of Disposition Qir..tUKt.) CrinJocIv.-
2 (address)
W
N
O (section) (lot number. (grave number)
pName of Sexton or Person in Charge of remises t hnsiOr t,,,t(t-
Z (please print)
W Signature J/
L Title CREI4iI 0(1
(over)
DOH-1555(02/2004)