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Cronquist, Roma Rita NEW YORKSTATE DEPARTMENT OF HEALTH �• Bureau of Vital Records Burial - Transit Permi Name First Middle Last Eale Roma Rita Cronquist Date of Death Age If Veteran of U.S.Armed Forces, 04/20/2020 90 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing Lo Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Roslyn Socolof MD Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 76 ❑Burial Date Cemetery,Crematory or Facility Name 04/22/2020 Pine View Crematory ❑Entombment Address Cremation Queensbury Town,New York ❑Donation ❑Removal Date Place Removed and/or and/or Held ~' Hold Address O Ix Date Point of to ❑Transportation `p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Date Cemetery Address ❑Reinterment 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 W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/21/2020 Registrar of Vital Statistics CarohneMiCcfegardeBar6er(ECectronicaCCySignec) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1ff Date of Disposition -I I77 70 Place of Disposition _ as (address/ (section) (lot numbe (grave number) Name of Sexton or Person in Charge of Pr vises i Z (Pi print) W Signature Title r DOH-1555(07/18)p 1 of 2