O'Brien, Dorothy Madeline i273
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dorothy Madeline O'Brien Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/09/2020 90 Years War or Dates
F, Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
`p Manner of Death 0Natural Cause ❑Accident ❑Homicide ❑Suicide ElUndetermined ❑Pending
V Circumstances Investigation
0ILI Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 221
Burial Date Cemetery,Crematory or Facility Name
12/10/2020 Pine View Crematory
Entombment Address
X❑Cremation Queensbury,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
Hold Address
CA
Q. Date Point of
(/) ❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/10/2020 Registrar of Vital Statistics Caroline Barher(Ef ctronicall:y Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z• Date of Disposition 170 Place of Disposition
W
(address)
W
+N (section) '
/�(lotnu` mber) 4 (grave number)
Name of Sexton or Person in Charge f Premises
Z (pleas print) �,,�
W (moot
Signature Title o►��Ut
DOH-1555 07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#