Dupuis, Song NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Song Cha Dupuis Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/19/2017 70 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑Natural Cause 0 Accident Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 650
❑Burial Date Cemetery or Crematory
12/20/2017 Pine View Crematory
-❑Entombment Address
®Cremation QueensburyTown, New York
Date Place Removed
ri❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment .-
by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
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 12/20/2017 Registrar of Vital Statistics R96ertACurtu rfectronwaaySigned.
(signature)
= District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition PM/7 Place of Disposition P,r,e re,) e-tY-4vt,dry
(addres
(section) (lot umber) (grave number)
Name of Sexton ,er o in Charge of Premises �1-'/"� C4.- o. e
(please print)
Signature Title e-re-msto47.
(over)
DOH-1555(02/2004)