Stanley, Dorothy Marie 13
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dorothy Marie Stanley Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/06/2023 80 Years War or Dates
i_ Place of Death Hospital,Institution or
W City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death ❑^ Natural Cause [11Accident Homicide nSuicide Undetermined []Pending
W
U Circumstances I (Investigation
ILI Medical Certifier Name Title
CI John Quaresima MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 18
Burial Date Cemetery,Crematory or Facility Name
02/08/2023 Pine View Crematory
Entombment Address
nCremation Queensbury Town,New York
lilDonation
ZZ❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
Q. Date Point of
U)nTransportation
p by Common Shipment
Carrier Destination
nDisinterment
Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
t.- Remains are Shipped,If Other than Above
g Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/07/2023 Registrar of Vital Statistics y7imeeL Maloney glectronicafSigner)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— "�
Z Date of Disposition AD 1d23 Place of Disposition 1 1 Pe c1 toc..) [/�te-}YI.L4r►-
W
2 (address)
W
U)
CC (section) (l t flambe!' (grave number)
O▪ Name of Sexton or Person in Charge Pre ise KA h�a�� 14)CP
please print)
Z
W Signature ry /14 Title ()e 4t
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 on burial permit
Official Funeral Directors Reg.or License#