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Nelson, Dora B.
. . If NEW YORK STATE DEPARTMENT OF HEALTH IZ Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Dora B Nelson Female Date of Death Age If Veteran of U.S.Armed Forces, 01/31/2021 97 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Hadley Town Street Address 89 Third Avenue,Hadley Town,New York 12835 WManner of Death © Natural Cause 1:1Accident Homicide ❑Suicide El Undetermined ❑Pending ✓ Circumstances Investigation E Medical Certifier Name Title Amy Johnson PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hadley 4558 3 ❑Burial Date Cemetery,Crematory or Facility Name 02/02/2021 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York ▪Donation Removal Date Place Removed and/or and/or Held N Hold Address toLi Transportation Date Point of is by Common Shipment Carrier Destination Date Cemetery Address DI 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 2 Remains are Shipped,If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/02/2021 Registrar of Vital Statistics Pauline G Smead(ECectronicalry Signed) (signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit Date of Disposition 2 Place of Disposition _1 C�-� 0(� W '3 Z (address) W CC (section) (lot nygiber) (grave number) gName of Sexton or Person in Charge of Premises / G/!h t„I �llS4I� z ( (please prin W Signature Title � M � DOH-1555(07/18)p 1 of 2 i Public Health Law Sec. 4145(2b) 014 L.q 0 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#