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Wiley, Donita L.
4' 30(d) NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donita L Wiley Female Date of Death Age If Veteran of U.S.Armed Forces, 03/24/2021 59 Years War or Dates F.. Place of Death Hospital,Institution or Z City,Town or Village Corinth Town Street Address 35 Gabriel Road,Corinth Town,New York 12822 ILI fa ©Natural Cause Accident Homicide Suicide Manner of Death Undetermined 0 Pending ILI Circumstances Investigation W Medical Certifier Name Title G Susan Dorsey MD Address 1 West Avenue,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Corinth 4553 7 ElBurial Date Cemetery,Crematory or Facility Name 03/26/2021 Pineview Crematory ElEntombment Address ElCremation Queensbury Town,New York Donation ZEl Removal Date Place Removed and/or and/or Held p usHold Address 0 a Date Point of to ❑Transportation p by Common Shipment Carrier Destination 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom N Remains are Shipped,If Other than Above Address SC O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/25/2021 Registrar of Vital Statistics Brenda L Penis(Electronically Signed) (signature) District Number 4553 Place Corinth, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit o • Z /� W Date of Disposition 3 1 Z�I if Place of Disposition )�� ,(a'�t� 2 (address) W (I) CC (sect,on) (lot number) r (grave number) gz Name of Sexton or Person in Charge of Pre ' s X to ,J J`"`/� (pr se print) W Signature Title tarn I�(� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01 4 670 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#