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Livingston, Ann it 3 NEW YORK STATE DEPARTMENT OF HEALTH `` Vital Records Section Burial - Transit Permit Name First Middle Last Sex Ann Livingston Female Date of Death Age If Veteran of U.S. Armed Forces, August 13, 2018 82 War or Dates Place of Death Hospital, Institution or City, Town or Village Argyle Street Address 26 Sams Kill Road Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ P Circumstances Investigation Medical Certifier Name Title CI Kristen Kelley, Address Death Certificate Filed District Number , Register Number City, Town or Village Argyle 15-.6 .>'1 ❑Burial Date Cemetery or Crematory August 16, 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 Date 1 Point of a.. ❑Transportation I Shipment O by Common Destination 0 Carrier _ ❑ Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077 Address 123 Main St., Argyle NY 12809 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address Jr 111 L. Permission is hereby granted to dispose of the human remai s described above as indicated. Date Issued �, Registrar of Vital Statistics QQ� 1 A,— .r j (signature) District Number 5150 Place .'gyi. Al I y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 08/16/2018 Place of Disposition Quaker Road Queensbury,NY 12804 1Z (address) ', (section) /�i(lot number) (grave number) Name of Sexton or Person in Charge of Premises!� G +� 1� ,S1"" 41 W (pl ase print) Signature ,4— Title (over) DOH-1555 (02/2004)