Dickinson, Dennis Carl Sr. 0 4 33z
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dennis Carl Dickinson Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/19/2022 78 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
aManner of Death EllNatural Cause Accident El Homicide Duicide Undetermined El Pending
Circumstances Investigation
• Medical Certifier Name Title
Shardul Koppar DO
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed Town Of Granville District Number Register Number
City,Town or Village 5756 21
Burial1 ]
Date Cemetery,Crematory or Facility Name
04/20/2022 Pineview Crematorium
Entombment Address
)Cremation Queensbury Town,New York
DDonation
Removal Date Place Removed
and/or Held
and/or
tl Hold Address
II Transportation Date Point of
a by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
Reinterment Il
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
F-' Remains are Shipped,If Other than Above
Address
cc
us
A. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/20/2022 Registrar of Vital Statistics Jenny Linda M Martelle(Electronically Signed)
/signature)
District Number 5756 Place Town Of Granville
i certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Lj/20 I 2Z Place of Disposition A741 f r.-_
(address)
Ut
g (section) (lot number) (grave number)
8'. Name of Sexton or Person in Charge of Premi a A 4 4 Z— c1, ft
(p ase print)
W Signature Title (Km I l'�,p
C
DOH-1555(07/18)p i of 2
01_5982
Public Health Law Sec. 4145(2b)
Receipt
a', r
Human remains of - . ` delivered on , 20
,. r
Pine View Cemetery Representing the funeral home named1op,ltrial permit
Official Funeral Directors Reg.or License#