Liberty, Dorothea G NEW YORK STATE DEPARTMENT OF HEALTH Burial- Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dorothea G Liberty Female
Date of Death Age If Veteran of US.Armed Forces,
11/27/2021 97 Years War or Dates
Place of Death Hospital.Institution or
WCity,Town or Village Ticonderoga Town Street Address Elderwood at Ticonderoga
p Manner of Death Natural Cause 0 Accident El HomicideSuicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
CI James Gabler PA
Address
1019 Wicker St,Ticonderoga Town,New York 12883
Death Certificate Filed District Number Register Number
City,Town or Village Ticonderoga 1564 61
EjBurial Date Cemetery,Crematory or Facility Name
11/30/2021 Pine View Crematory
ElEntombment Address
ElCremation Queensbury Town,New York
EDDonation
O Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a Date Point of
CO Li Transportation
p by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
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 11/30/2021 Registrar of Vital Statistics Tarr}tz,3f7tompsnn( lectrmricalFySitned)
(signature)
District Number 1564 Place Ticonderoga, New York
I certify that the remains of the decedent identified above were disposed of in accordance with thish permit on:
if, Date Date of Disposition /a-,?-2 Place of Disposition e V)ret� (rem 4,-64-
2 (address)
W
CC ��
(section) "number? (grave number)
0 .?A AVM CI'
0 Name of Sexton or Person in Ch a of Pre 'splea�^'
se print)
• Sibnaturc Title C�
DOH-1555(o7h8)p 1 of 2
•
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#