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Poole, Frances NEW YORK STATE DEPARTMENT OF HEALTH H )3 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Frances M. Poole Female Date of Death Age If Veteran of U.S. Armed Forces, October 2, 2017 89 War or Dates Place of Death Hospital, Institution or W City, Town or Village Moreau Street Address 9 Hudson Drive IR Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending C Circumstances Investigation W Medical Certifier Name Title 0 Charles Yun, Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Moreau 0 Burial Date Cemetery or Crematory October 4, 2017 Pine View Crematory 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held and/or Address g- Hold Date Point of ['Transportation Shipment ft by Common Destination a Carrier Disinterment Date Cemetery Address 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 IPermission is herebyl `-fgranted to dispose of the human remai escribed abov indicated. Date Issued 10 /0/ 17 Registrar of Vital Statistics 1 L / �, (signature) I District Number 245 d . Place 'Zr77,0 62/e...11.S .11 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition 10/04/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) C (section) (lot number) (grave number) .91 Name of Sexton or Person in Charge of emises ��r s}rr- So.�1l /1/ (pie se print) Signature GL 1 /�'G�" g '�' Title (IZFm1tii7 -- (over) DOH-1555 (02/2004)