Simpson, Marie C. 4 303
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marie C Simpson Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/02/2020 91 Years War or Dates
I-, Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause 1:1Accident 1:1Homicide 1:1Suicide Undetermined ❑Pending
LLI Circumstances Investigation
U
W Medical Certifier Name Title
0 Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 154
Burial Date Cemetery,Crematory or Facility Name
04/03/2020 Pineview Crematory
Entombment Address
RI Cremation Queensbury Town,New York
Donation
OZ Removal Date Place Removed
and/or and/or Held
~ Hold Address
O
O. Date Point of
U) Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
l.- Remains are Shipped,If Other than Above
Address
W
CI' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/03/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed)
(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:
H
Z Date of Disposition 3 ,� Place of Disposition tv
W (address)
2
W
N (sedan) llot number (grave number)
a Name of Sexton or Person in Charge of emises �j�
�
� ease print
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) r1 j
Receipt
Human remains of delivered on : , 20
Pine View Cemetery Repr6senting the funeral home named on burial permit
Official Funeral Directors Reg.or License#