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Butler, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH s fl 3 ? cf Vital Records Section Burial - Transit Permit Name First Middle Last Sex Marjorie Mary Butler Female Date of Death Age If Veteran of U.S. Armed Forces, May 7, 2017 88 War or Dates ZPlace of Death Hospital, Institution or City, Town or Village Argyle Street Address Washington Center Ll Manner of DeathrnNatural Cause Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title Edit Masaba, MD Dr. Address 35 Gilbert Street Greenwich, NY 12834 Death Certificate Filed District Number SAS Register umber City, Town or Village Argyle 0 Burial Date Cemetery or Crematory May 9, 2017 Pine View Crematory Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address p Hold V) Date Point of ❑Transportation Shipment Cl) by Common Destination f Carrier Date Cemetery Address ❑ Disinterment ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above 2 Address aC W 0' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 51 q /a4,l 7 Registrar of Vital Statistics ,�I� � Q ti `� (signature) District Number 5150 Place 0 1Y to_ kl y • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H W Date of Disposition 05/09/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W (section) ,,(lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises h r ��'''^t (pleOse print) W SignatureLA Title (over) DOH-1555 (02/2004)