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Pullen, Sally NEW YORK STATE DEPARTMENT OF HEALTH ft Vital Records Section Burial - Transit Permit Name First Middle Last Sex Sally Letitia Pullen Female Date of Death Age If Veteran of U.S. Armed Forces, April 29, 2017 80 War or Dates Place of Death Hospital, Institution or it City, Town or Village Moreau Street Address 430 Selfridge Road W Manner of Death 0 Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title C Robert P Reeves, Dr. Address Three Irongate Center Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Moreau �/C(c o2 V ❑Burial Date Cemetery or Crematory May 2, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address F Hold NM Date Point of o. ❑Transportation Shipment OT by Common Destination 6 Carrier Date Cemetery Address 0 Disinterment Date Cemetery Address 0 Reinterment Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 - Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address ie w- EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 51 /II 7 Registrar of Vital Statistics 4/2& >I/ ", 21-c (signature) District Number V Q., a Place 766/4 0 f /HO,CC t I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition 05/02/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W (section) �i (lot number) (grave number) 2 Name of Sexton or Person in Charge of Premises el. +t =St�►11(h" (p ase print) 1 Ul Signature 0 Title Etn i) (over) DOH-1555 (02/2004)