Mondoux, Margery NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
. s Name First Middle Last Sex
Margery Anne Mondoux Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/19/2017 88 Years War or Dates
8 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitati
Manner of Death 0 Natural Cause El Accident 0 Homicide E Suicide El Undetermined 0 Pending
ri
Circumstances Investigation
Medical Certifier Name Title
Gwendolyn Morris-Dickinson PA
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 596
❑Burial Date —1 Cemetery or Crematory
11/21/2017 Pine View Crematory
El Entombment Address
-'®Cremation Queensbury Town, New York
Date l Place Removed
.: El Removal
and/or Held
Address
Hold
9 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
` Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
tAddress
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/21/2017 Registrar of Vital Statistics s 6enACurt's EtectronicalrySigned-
r (signature)
District Number Place
5601 Glens Falls, New York
oo
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /I/1ifl l Place of Disposition -em11.�.i ��ma,t.Q—
(address)
(section) 4 (lot number) (` (grave number)
0 Name of Sexton or Person in Charge of Pre ises ik, J taim
( lease print)
Signature /1 Q" Title (tlMf1lZ-
(over)
DOH-1555 (02/2004)