Dingman, Shirley T NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Pern it
Bureau of Vital Records
Name First Middle Last Sex
Shirley T.Dingman Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/15/2021 88 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Gloversville Street Address Nancy Dowd Hospice Home
'p Manner of Death II Natural Cause Accident Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Gloversville 1701 52
0 Burial Date Cemetery,Crematory or Facility Name
02/17/2021 Pine View Crematory
0 Entombment Address
0 Cremation Queensbury Town,New York
0 Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
Vl
0
G. Date Point of
Cl) ❑Transportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
f. Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/17/2021 Registrar of Vital Statistics Devon Davis gkctronica*4/nea
(signature)
District Number 1701 Place Gloversville, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH
Z Date of Disposition a-ad-ip,,j Place of Disposition P,` ��� /),44) L'
(address/
W
CC N (section) (lot number) (grave number)
E.G Name of Sexton or Person in Cha e of Premises/ Af'�00,'r' �`�
Z } f� / (please print)
W Signature ‹j/If/ ;' l Title � 2n5 D l'
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) -fit
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# _