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Ambler, Virginia ' ii NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Virginia H. Ambler Female ': Date of Death Age If Veteran of U.S. Armed Forces, 3/15/95 92 War or Dates No 144 Place of Death Hospital, Institution or Z City, Town or Village Glens Falls Street Address Glens Falls Hospital © Manner of Death C Natural Cause El Accident El Homicide 0 Suicide 0 Undetermined 0 Pending Circumstances Investigation Medical Certifier Name Title ip Bernardo R . villajauan MD gi Address 90 SO.Street Glens FAlls,NY Death Certificate Filed I District Number Register uJer iia City, Town or Village Glens Falls 5601 ,/` s Date ' Cemetery or Crematory Burial 3/1.8/95 Pine view Cemetery Address ❑Cremation Queen shury,NY Date ' Place Removed Z 0❑Removal and/or Held and/or Address }'" Hold th Q Date j Point of N['Transportation j Shipment a by Common Destination Carrier Disinterment Date Cemetery Address 1 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home slum jiguitAmcimm 01877 Address 67 PARK STREET GLENS FALLS NY 12801-4454 .,,.,:]i'ii Name of Funeral Firm Making Disposition or to Whom La Remains are Shipped, If Other than Above Address tg 1 Permission is hereby granted to dispose of the human remains des ribed above as ind' ated. i Date Issued '1/1 7/05 Registrar of Vital Statistics ` / Z . (signature) iiiiii District Number 5601 Place r1 Pn c Pall c,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f- Z Date of Disposition 3/18/95 Place of Disposition Pine View Cemetery Queensbury NY 12804 2 (address) iU CA Mohawk 137 1 CC (section) (lot number) (grave number) GName of Se : . Person in Charge of Premises Rodney G. Mosher Z p (please print) W Signature _A, • ,.. \Ike,-.2 Title Suot . DOH-1555 (10/89) p. 1 of 2 VS-61 A