Middleton, Doris May li
NEW YORK STATE DEPARTMENT OF HEALTH - LF l
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Doris May Middleton Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/23/2022 92 Years War or Dates
1.. Place of Death Hospital,Institution or
WCity,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
p Manner of Death ❑X Natural Cause DAccident El Homicide ❑Suicide DUndetermined Pending
fJ Circumstances Investigation
W Medical Certifier Name Title
t7 Leah Terry NP
Address
4837 4837 State Route 40,Argyle Town,New York 12809
Death Certificate Filed Town of Argyle District Number Register Number
C ,Town or Vi lla$e 5750 46
Burial Date Cemetery,Crematory or Facility Name
08/29/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
pN Hold Address
0
IL Date Point of
U)ElTransportation
a by Common Shipment
Carrier Destination
Disinterment 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
1— Remains are Shipped,If Other than Above
5" Address
CC
ii' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/29/2022 Registrar of Vital Statistics Sie/y.wckfnron(fEIetmmcaiySJnea)
(signature)
District Number 5750 Place Town of Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I' �J,
Z Date of Disposition $130 12Z Place of Disposition �../ /�--
su
2 (address)
W
CC CC (sedion) (lot number/ (grave number)
Abcy_g Name of Sexton or Person in Cha miles ,,,,.(Z irt
please print)
IU Signature Title
DOH 1555(07/18)p 1 of 2
6.LvJ
Public Health Law Sec. 4145(2b)
Receipt
Human remains of _ delivered on , 20
Pine View Cemetery Representing the funeral home named pn burial permit
Official Funeral Directors Reg.or License#