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Bixler, Kim r NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Kim P Bixler Female tt Date of Death Age If Veteran of U.S. Armed Forces, 12/13/2017 62 Years War or Dates IA Place of Death Hospital, Institution or d City,Town or Village Granville Village Street Address Indian River Rehabilitation And Nursing Center Manner of Death©Natural Cause ❑Accident El Homicide ❑Suicide Undetermined Pending Circumstances Investigation -' Medical Certifier Name Title Sean Bain MD iil , Address 17 Madison St,Granville Village,New York 12832 Death Certificate Filed District Number Register Number City, Town or Village Granville Village 5725 43 ❑Burial Date Cemetery or Crematory 12/18/2017 Pine View Crematory ❑Entombment Address ®Cremation Queensbury, New York ` Date Place Removed ❑Removal and/or Held and/or - Address Hold Date Point of p, ❑Transportation Shipment -" by Common Destination 1, Carrier Q Disinterment Date Cemetery Address - Date CemeteryAddress ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above -T7. Address , Permission is hereby granted to dispose of the human remains described above as indicated. 4 Date Issued 12/15/2017 Registrar of Vital Statistics 4tichari 6erts E1 ctrmicaQySigned (signature) t District Number 5725 Place Granville Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition al lc I n Place of Disposition .A1--1 �+*,.S,74P--- - (address) (section) (lot number (grave number) Name of Sexton or Person in Charge of Pre ises G 1y 4,...4 ' (piease print Signature A pv► Title (REM (over) DOH-1555 (02/2004)