Hoffman, Dorothy Jean NEW YORK STATE DEPARTMENT OF HEALTH L�
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dorothy Jean Hoffman , Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/18/2022 97 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
W Manner of Death g
0 �Natural Cause Accident �Homicide Suicide Undetermined �Pendin
W Circumstances Investigation
W Medical Certifier Name Title
CI Elizabeth Bessette NP
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 109
Burial Date Cemetery,Crematory or Facility Name
07/22/2022 Pine View Cemetery
Entombment Address
IliCremation Queensbury,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
IL Date Point of
Cl)ElTransportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
f.. Remains are Shipped,If Other than Above
a Address
Ilr
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/20/2022 Registrar of Vital Statistics Caroline.-(i[degardeBar6er(ECectronicallySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit onn:que_r_nStx_i
^I /r�L}�
W Date of Disposition /.9.c Place of Disposition 9/ O( Q f(,?J2 I A ry /V 1 f��';
(ass) /
W section) icciJN `,/l/number) (graveumber)
GName of Sexton or Person in •Charge of Prem. s n<< `-'"'� '7
Z (please print)
Ili Signature Z. 1' Title J f?? 1 0 -�e,/�Cl�
DOH-1555(07/18)p 1 of 2
1
Public Health Law Sec. 4145(2b) 012930
Receipt
x. , , t, . 4. ,
y
Human remains of 1 ;i
�� 1 f v ..delivered on- ' , 20
i 1k
,,,,,/„./s1,tie View Cemetery Representing the funeral home named on burial permit
;Official Funeral Directors Reg.or License# t
`,.
HOFFMAN
NAME Dorothy Jean Hoffman Age: 97
Lot Owner: Jean Hoffman
Lot# Mohican 56 B Grave# 2
Case: Concrete
Died: 7. 1 8.2 2 Interred: 7•2 2•2 2
Funeral Home: Singleton Sullivan Potter
Cemetery: Pine View