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Lacko, Dorothy Mae NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dorothy Mae Lacko Female Date of Death Age If Veteran of U.S.Armed Forces, 11/02/2023 91 Years War or Dates 1— Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 11.1 WManner of Death Natural Cause Accident n Homicide Suicide []Undetermined ❑Pending I Circumstances Investigation W Medical Certifier Name Title l7 Sean Bain 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 513 []Burial Date Cemetery,Crematory or Facility Name 11/06/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Z❑Removal Date Place Removed and/or and/or Held N Hold Address 0 Il Date Point of N Transportation p by Common Shipment Carrier Destination oDisinterment Date Cemetery Address Date Cemetery Address E Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the hu an remains described above as indicated. Date Issued 11/06/2023 Registrar of Vital Statistics Megan.NbingYectronrcallySignea9 (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: I— j Z Date of Disposition 111� 173 Place of Disposition r11/64,;6,v o ,mgMei"— W 2 (address) W CC N (sect on) (lot number) (grave number) Name of Sexton or Person in Charge o P emises t' Lr� (pllese print) Z W INCA ITV Signature Title DOH-1555(07/18)p i of 2 017636 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery 'epresenting the funeral home named on burial permit Official Funeral Directors Reg.or License#