Adriatico, Dorothea UNEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dorothea Adriatico Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/25/2022 68 Years War or Dates
H Place of Death ._Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
p Manner of Death II Natural Cause Accident Ei Homicide Suicide ❑Undetermined Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
G Scott Biasetti MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 390
Burial"]
Date Cemetery,Crematory or Facility Name
07/27/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
O. Date Point of
N) Transportation
p by Common Shipment
Carrier Destination
Disinterment El
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
I— Remains are Shipped,If Other than Above
N Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/26/2022 Registrar of Vital Statistics Megan Wolin(ECectronica1ySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z i
W Date of Disposition 7—}.J�.} Place of Disposition ;�.Q,V �G� (J�C�iddress)
`, )l
'
W
N LC (section) (lot number) (grave number)
(
G Name of Sexton or Person in Charge of Premises J Ti^Gy J t(t.S
Z ' yplease print)
W Signature �/ 4/ Title C,rGr ,,,r
DOH-1555(07/18)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-en bulta1 permit
Official Funeral Directors Reg. or License#