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Misner, Dolores F. . $ SII NEW YORK STATE DEPARTMENT OF HEALTH ,:• Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dolores F.Misner Female Date of Death Age If Veteran of U.S.Armed Forces, 07/16/2021 88 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 19 Sycamore Drive,Queensbury Town,New York 12804 W Manner of Death Pending 0 ©Natural Cause �Accident �Homicide �Suicide �Undetermined � W Circumstances Investigation W Medical Certifier Name Title 0 William Borgos MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 149 ❑Burial Date Cemetery,Crematory or Facility Name 07/21/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury,New York Donation Z ❑Removal Date Place Removed and/or and/or Held h N Hold Address 0 Date Point of co Li Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address 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 W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/20/2021 Registrar of Vital Statistics Caroline xf1egarde Barber(ECectronicaffySigned) (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 ) Place of Disposition ��� 1/ c,re ry W (address) W N (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises c.)c,Cr,ei)' Sty.rtS (please print) W iy � Title CiCe'rn`'f" Signature �i�'�' `�`Z✓ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) U 14 9 5 9 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#