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Speyer, Ellen NEW YORK STATE DEPARTMENT OF HEALTH +' # Sit Vital Records Section Burial - Transit Permit o, Name First Middle Last Sex Ellen C. Speyer Female Date of Death Age If Veteran of U.S. Armed Forces, June 23, 2018 �� War or Dates Place of Death ( � Hospital, Institution c 'ff- City, Town or Village A C Street Address r�Q 53 \ 5 *fManner of Death 'Natural Cause Accident I I Homicide I I Suicide Undetermined Peding Circumstances Investigation 2 Medical Certifier Name Tiv)Christopher Terrien, Address 319 So. Manning Blvd Albany, NY 12208 Death Certificate Filed wtopiviiiDistrict Number O 101 Register i Number City, Town or Village ❑Burial Date Cemetery or Crematory June 26, 2018 Pine View Crematory 0 Entombment Address _ ,-©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z Removal and/or Held and/or Address Hold a Date Point of ElTransportation Shipment by Common Destination Carrier Disinterment 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 Z(o Z Permission is hereby granted to dispose of the human rema' s describedabove as indicated. . Date Issued egistrar of Vital Statistics ,/ G (signature) District Number 0101 Place C1 04- / 'OC k_ certify that the remains of the decedent identified ove were disposed o i accordance with this permit on: Date of Disposition 06/26/2018 Place of Disposition Quaker Road Queensbury,NY 12804 g. (address) (section) a (lot number) (grave number) 0 Name of Sexton or Person in Charge f Premises ( Si^i,iit ( lease print) Signature4 Title CR,FfilA7atL (over) DOH-1555 (02/2004)