McDougall, Patricia NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia Ann McDougall Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/16/2018 83 Years War or Dates
1-- Place of Death Hospital, Institution or
iu. City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Q Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
UI Circumstances Investigation
W Medical Certifier Name Title
Q Jean Vanauken PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 393
❑Burial Date Cemetery 6i C atory
08/16/2018 Pine View Cremat
El Entombment Address ,
®Cremation Queensbury Town, New York
Date Place Removed
Z❑Removal and/or Held
12 and/or Address
b Hold
ttn.
0 Date Point of
lik❑Transportation Shipment
CI by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
E Remains are Shipped, If Other than Above
Address
W
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/16/2018 Registrar of Vital Statistics 1'hhen.,1 Curtis(ECectranica1TySigned)
(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:
W Date of Disposition gi 11 l ig Place of Disposition O. '
W (address)
to
tt (section) (lotnumle c (grave number)
pName of Sexton or Person in Charge of Premises 6G/1 c.TI�
Z ,�I (Ply print)!
W Signature l Title Of"i&
(over)
DOH-1555(02/2004)