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Kingsley, Shirley A
A It 11911 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle , Last Sex Shirley A Kingsley qFemale Date of Death Age If Veteran of U.S.Armed, rces, 12/12/2021 85 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital p Manner of Death © Natural Cause El Accident 0 Homicide Suicide 0 Undetermined Pending W Circumstances Investigation CI W Medical Certifier Name Title a Catherine Dawson MD Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 730 ElBurial Date Cemetery,Crematory or Facility Name 12/15/2021 Pineview Crematory ❑Entombment Address lCremation Queensbury Town,New York ❑Donation F. 0 Removal Date Place Removed and/or and/or Held H Hold Address N 0 1-1 Date Point of U) ❑Transportation Shipment Q by Common 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 t.. Remains are Shipped,If Other than Above a Address Q W d Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/14/2021 Registrar of Vital Statistics John Paul Franck(Electronically Signed) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this perm' n: I— W Date of Disposition I Z I 15171 Place of Disposition r��L-/ /400---- W N CC (section) `/nl (section) �( (lot number) (grave number) 0 Name of Sexton or Person in Charge of ises t1 y Sith.4,(� Z (plea print) W Signature Title DOH-1555(07/18)p 1 of 2 (L5442 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#