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Repass, Dorothy Edith -i aZ NEW YORK STATE DEPARTMENT OF HEALTH I ' Burial Bureau of Vital Records • - Transt Permit Name First Middle Last Sex Dorothy Edith Repass Female Date of Death Age If Veteran of U.S.Armed Forces, 10/24/2021 84 Years War or Dates �., Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Ur 'etermined ❑Pending C.) ,stances Investigation W Medical Certifier Name Title Asim Chaudry MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 467 ❑Burial Date Cemetery,Crematory or Facility Name 10/28/2021 Pine View Crematory EiEntombment Address lCremation Queensbury Town,New York O Donation ZO Removal Date Place Removed and/or and/or Held Hold Address N 0 CL U) Li Transportation Date Point of p 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 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/27/2021 Registrar of Vital Statistics c96ertAndrew Curtis(ECectronica/Ty Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition jD- �e1/Place of Disposition Pi Ale �A.�'�� �I-�jy►7r�, p�'`� (address) J W CC (section) > j (lot num� (grave number) Name of Sexton or Person in Char of Premises 'C � I'l�l�r� !J� `r (please print) tJV Signature 7 ` d C y Title � DOH-1555(07/18)plof2 0 :15268 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#