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Cornwall, Pauline _! 7 1 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Pauline Marie Cornwall Female s Date of Death Age If Veteran of U.S. Armed Forces, July 25, 2017 62 War or Dates Place of Death Hospital, Institution or City, Town or Village Granville Street Address Haynes House of Hope in Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title MI Anthony Petracca, Dr. Address 3 Irongate Center Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Granville 5n6 LP ❑Burial Date Cemetery or Crematory July 26, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address E Hold Date Point of 0 ❑Transportation Shipment by Common Destination rt Carrier I Disinterment Date Cemetery Address F ❑ Reinterment Date Cemetery Address ._ Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE I 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued `, I ale I �p'registrar of Vital Statistics lk)._ n a (signature) District Number59 SCe Place 1 ot_ i'-) 40 c e(' Vi 1\-e I certify that the remains of the decedent identified above were disposed of in accor4ance with this permit on: /hevi`dM) Grern '/ Date of Disposition 07/ 2017 Place of Disposition Quaker Road Queensbury,NY 12804 ,; (address) (section) (lot number) (grave number) Vik Name of Sexton or s in Charge of Premises 31^'1' �G Zh (please print)l Of Signature Title (over) DOH-1555 (02/2004)