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Millington, Marlene 3(a _ NEW YORK STATE DEPARTMENT OF HEALTH K7 Vital Records Section _ Burial - Transit Permit Name First Middle Last Sex Marlene $1. Millington Female Date of Death Age If Veteran of U.S.Armed Forces, August 14,2006 75 War or Dates F— Place of Death City of Glens Falls Hospital, Institution or Glens Falls Hospital Z City,Town or Village Street Address W Manner of Death © Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending 113 W Circumstances Investigation W Medical Certifier Name Title CIDr.Daniel Way Mp Address HHHN,Warrensburg,NY 12885- Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 3 cj 3 0 Burial Date Cemetery or Crematory 8/16/2006 Pine View Crematory ❑ Entombment Address ® Cremation Queensbury,NY Date Place Removed O 0 Removal and/or Held and/or Address F. Hold a Date Point of ❑ Transportation Shipment by Common Destination u Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00036 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above - Address IE la aa. Permission is hereby granted to dispose of the human remains describes!/above as i icat Date Issued 08-15-06 Registrar of Vital Statistics ..Z �3� 4_,.. (signature) District Number 5601 Place Glens Falls,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition .•; . 0�, A.1- Place of Disposition n i ti^w {.,,,„ z T ,,., (address) W Cl) (section) (lot number) (grave number) © Name of Sexton or Person in Charge of Premises / h r.s j r;I f,,, 11-' Z .j (please print) W Signature f('`,A. -4i-+.,t'"'- Title (u i -r r t-.,r DOH-1555(02/2004) (over)