Dutcher, Gail Ciao
NEW YORK STATE DEPARTMENT OF HEALTH -Vital Records Section Burial Transit Permit
Name First Middle Last Sex
Gail P. Dutcher Female
Date of Death Age If Veteran of U.S.Armed Forces,
F January 8, 2006 60 War or Dates
Z Place of Death 4-CU.j) c `� Hospital, Institution or
W City,Town, or Village Salem 1_i e 1,,(,,A Street Address Own Home
G Manner of Death X❑ Natural Cause ❑Accident E Homicide ESuicide E Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Ageel A. Gillani, M.D. Dr.
Q Address
102 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Salem
❑Burial Date Cemetery or Crematory
January 10, 2006 Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑ Removal and/or Held
- and/or Address
r Hold
0 Date Point of
4 E Transportation Shipment
d by Common Destination
i Carrier
Date Cemetery Address
a ❑Disinterment
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01140
Address
123 Main St. , Argyle, New York 12809
1-
Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
CC
W Address
O.
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 0 / - /C - 0 (. Registrar of Vital Statistics i t . z k/c� isz ��c-4 r- 1-
(signature) V
District Number ';'76. C Place Salem,New York
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 01/10/2006 Place of Disposition Pine View Crematory
2 (address)
W
N
0 Ie (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises C9-4/ZY 64Z /11
Z l (please pnnt) II
W0
) �,
Signature - Title 6j E �C/
(over)
DOH-1555 (02/2004)