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Grogan, Geraldine NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit iiiiiiiiiii Name First Middle Last Sex Female Geraldine Marie Grogan >; Date of Death Age If Veteran of U.S. Armed Forces, 5, 1999 77 War or Dates February Place of Death Hospital, Institution or ICity, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Deathfuj Undetermined Pending '.Q Natural Cause Accident Homicide Suicide ❑Circumstances Investigation 'iii Medical Certifier Name Title P MD Thomas Kandora MD Address iiiiiiiiii Broadway, Fort Edward, NY 12828 Register Number iiiilillii Death Certificate Filed District Number 5 �� L City, Town or Village Glens Falls / 9 O Date Cemetery or Crematory LJ Burial February 5, 1999 I Pine View Crematory Address ©Cremation Quaker Road Queensbury, NY 12804 Date Place Removed 2❑Removal and/or Held and/or Address Hold 0 Date Point of 134 Q Transportation Shipment 5 by Common Destination Carrier Date Cemetery Address Disinterment Date Cemetery Address Reinterment Permit Issued to Registration Number tiii Name of Funeral Home M. B. Kilmer Funeral Home 01057 iiiiig Address ill 82 Broadway, Fort Edward, NY 12828 • Name of Funeral Firm Making Disposition or to Whom it Remains are Shipped, If Other than Above Address lz IN rx iliii Permission is hereby granted to dispose of the human remains describ d abo e a 'n i e . Date Issued 218I ci9 Registrar of Vital Statistics _ 6 (signature) iNii bi I:iii: District Number 56 U ► Place Glens Falls,New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �',4) Ciecc" o�'��/ ZDate of Disposition oz`O9"// Place of Disposition ,/� d 2 (address) - - (section)(13 CC f (lot number) / (grave number) Name of Sexton or Person in Charge of Premises . .ill /// l I/ IV)/9 T�� 4-1 CI Z Avr. _ __)./ ./t.. .,,,ex_445_,,, (please print) Jry ,453>7-' � Signature Title d DOH-1555 (10/89) p. 1 of 2 VS-61