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Moon, Myrtle I �'� 4- zq7 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Myrtle Katheryn Moon Female p. • Date of Death Age If Veteran of U.S.Armed Forces, 04/02/2018 84 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing Manner of Death �' ©Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined �Pending i 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 47 41,El Burial Date Cenietery or Crematory 04/05/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed i❑Removal and/or Held and/or Address Hold 21 Date Point of t 0 Transportation Shipment ,., by Common Destination Carrier Q Disinterment Date Cemetery Address 11 Renterment Date Cemetery Address 3, Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 ipi Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom L Remains are Shipped, If Other than Above Address ii ® Permission is hereby granted to dispose of the human remains described above as indicated. t r, Date Issued 04/05/2018 Registrar of Vital Statistics Caroline 9(Bar6er(ElectronicallySigned) (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: Date of Disposition tj/lig Place of Disposition �,JV—, tef,_, I (address) xz °,` (section) (lot number 1 (grave number) I Name of Sexton or Person in Charge of Premises n. //���� '1 (pha ,..of print) GC Signature /i, r Titlet►1tv. (over) DOH-1555(02/2004)