Couch, Marilyn Y a
NEW YORK STATE DEPARTMENT OF HEALTH `
Vital Records Section Burial - Transit Permit
i Name First Middle Last Sex
• Marilyn Couch Female
Date of Death Age If Veteran of U.S. Armed Forces,
5P 07/15/2018 82 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
fa' Manner of Death Eej Natural Cause 0 Accident E Homicide 0 Suicide 0 Undetermined El Pending
Mr Circumstances Investigation
Medical Certifier Name Title
001 Rick Teetz MD
Address
131 Lawrence St,Saratoga Springs,New York 12866
=; Death Certificate Filed District Number Register Number
.; City, Town or Village Saratoga Springs 4501 406
• ❑Burial Date Cemetery or Crematory
07/19/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Rmoved
Removal and/or eld
and/or Address 1
'74 Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
• Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
rit
rS
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 07/18/2018 Registrar of Vital Statistics John P Franckg(ectronica1TySigned)
(signature)
District Number 4501 Place Saratoga Springs, New York
itt
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition )-a-3—tg Place of Disposition Q fine, 1r,t,k' Gfr✓,Aq{ary
61 (address)
v (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises th+L y Se,VI rc.5
(please print)
rill
Signature 19/
.' Title Gfttito V r
(over)
DOH-1555 (02/2004)