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St. Croix, Ann NEW YORK STATE DEPARTMENT OF HEALTH ,r -, 1 Vital Records Section Burial - Transit Per y hiit Name First Middle T Last Sex Ann Rose St. Croix Female Date of Death Age If Veteran of U.S. Armed Forces, October 16, 2018 62 War or Dates Place of Death >//� Hospital, Institution or i' City, Town or Village A /,t?Q.. Street Address St. Peters Hospital Manner of Death La rk—kNatural Cause ❑ Accident ❑ Homicide ❑ Suicide Undetermined ❑ Pending `� Q4- - Circumstances Investigation Medical Certifier rl�� J\ l `� Ti 0f'� '" 1 Vfn. 'RNA ' )koie 6a3/4-14- -- (T/ *Aug ,04 Death Certificate Filed District Number Register Number City, Town or Village Atha('an 010 ( 44187 ❑Burial Date Cemetery or Crematory El Entombment E0'' 3 6 V Pine View Crematory Address 1.©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address -_ Hold Date Point of ❑Transportation Shipment by Common Destination 0 Carrier ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number ;,€ Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 °` Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address 1. Permission is hereby granted to dispose of the human remains d cribed a s indicated. Date Issued /p/ /gyp/s-Registrar of Vital Statistics -f f /l / (sig ture) District Number 0/0/ Place C/1/ ' /94 a----, V 1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition It,ill lig Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (I t number) (grave number) Name of Sexton or Person in Charge of Premises /41,. Si.A�f (pleake print) Signature 14 Title Ittki0AIV) (over) DOH-1555 (02/2004)