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Elms, Geneva NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Fit Geneva M.Elms Female Sr Date of Death Age If Veteran of U.S. Armed Forces, 'Zil' 07/27/2018 88 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls ! Street Address Glens Falls Hospital Manner of Death Xj Natural Cause Accident j% Homicide 1 Suicide Undetermined Pending --- Circumstances Investigation Medical Certifier Name Title y, Scott Biasetti MD Address c 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 i 358 7 Pi L Burial Date C Cemetery or Crematory v.: 07/30/2018 PineView Crematorium ., Li Entombment Address IBC Cremation Town of Queensbury, New York -- Pik Date Place Removed r,j Removal and/or Held # and/or Address Hold Jd t.¢ 1 Date Point of L Transportation Shipment 1 by Common Destination Carrier _ t Disinterment Date Cemetery Address ' r--, Date Cemetery Address , I Reinterment Permit Issued to Registration Number ',7;",r Name of Funeral Home Mason Funeral Home 101117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 r Name of Funeral Firm Making Disposition or to Whom l Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. . Date Issued 07/30/2018 Registrar of Vital Statistics Ro6ertA Curtis(Electronica1Ty Signed) Wo- (signature) District Number Place "� 5601 Glens Falls, New York I"r,: -- "'aY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition Place of Disposition (address) rr (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises (please print) Signature Title (over) DOH-1555 (02/2004) 6007 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section i Burial - Transit Permit Name First Middle N- Last Sex Geneva M. F Elms Female At Date of Death Age If Veter of U.S. Armed Forces, 07/27/2018 88 yrs,,, War Dates n/a .1 Place of Death --Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital tiiilk Manner of Death©Natural Cause p Accident 0 Homicide 0 Suicide riUndetermined Pending to Circumstances Investigation ill Medical Certifier Name Title 0 Scott Biasetti MD_ Address 100 Park St. , Glens Falls, NY. 12827 Death Certificate Filed District Number Register Number `: City, Town or Village Glens Falls 6-6 40 >> ❑Burial Date Cemetery or Crematory July 30, 2018 PineView Crematorium >`❑Entombment Address ❑x Cremation Town of Queensbury, NY- Date Place Removed Z E Removal and/or Held and/or Address E Hold CO 0 Date Point of Transportation Shipment a by Common Destination gi Carrier Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address : Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 0111 7 Address 18 George St. , PO. Box 277, Fort Ann, NY. 12827 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address 0 t• Permission is hereby granted to dispose of the human remains de ribe ab e a ,dated. Date Issued 0 7/30/1 8 Registrar of Vital Statistics /Jim (signature) iig District Number 5601 Place City of Glens Falls, NY. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: M 111 Date of Disposition 7/30/)i Place of Disposition p;,ve,V x, Cf e,olcdoir)/ (address) LEE i CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises Je-Ce4dY ecS-).r.e.S Z (please print) Signature Title /C,C4-049Gr (over) DOH-1555 (02/2004)