Dean, Angela NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Angela "Angie" Dean Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 3, 2018 40 War or Dates
Place of Death Hospital, Institution or
," City, Town or Village Moreau Street Address
Manner of Death❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined Pending
( Circumstances Investigation
Medical Certifier Name Title
gt
Susan Hayes-Masa,
Address
40 McMaster Street Ballston Spa, NY 12020
Death Certificate Filed District Number 5� Register Number
City, Town or Village Moreau
®Burial Date Cemetery or Crematory
January 8, 2018 Pine View Cemetery
0 Entombment Address
❑Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
Date Point of
I:Transportation Shipment
'iby Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
t::. Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued //SP - Registrar of Vital Statistics y - /L/ ��- &--�
(signature)
District Number c�5(0 2. Place TO ts.)/1 of MO ce&'---
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tt.
o Date of Disposition 01/08/2018 Place of Disposition Quaker Road Queensbury,NY 12804
ill ., f (a .4s) C.
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szt
ion) / (lot number) (grave number)
2 Name of S n or Person in Charge of Premises O,C9lt9/6 G. 603 ' a—
G'1 (please nt)
iii Signatur pLLt . ^ Title /
(over)
DOH-1555 (02/2004)