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McCullough, Debbie NEW YORK STATE DEPARTMENT OF HEALTH 7t 3Oyy Vital Records Section Burial - Transit Permit Name First Middle Last Sex iv Debbie E McCullough Female Date of Death Age If Veteran of U.S. Armed Forces, 06/29/2017 55 Years War or Dates Place of Death Hospital, Institution or s City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause Accident ❑Homicide ❑Suicide nUndetermined ri Pending Circumstances Investigation Medical Certifier Name Title Frances Bollinger MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number *. City, Town or Village Glens Falls 5601 357 ❑Burial Date Cemetery or Crematory 07/03/2017 Pineview Crematory Li Entombment Address iiig®Cremation Queensbury, New York Date Place Removed ❑ Removal and/or and/or Held Address ,Ilt Hold Date Point of ❑Transportation Shipment by Common Destination Carrier , Q Disinterment Date Cemetery Address r Q Reinterment Date Cemetery Address � Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 1.0 24 Church Stpo Box 500, Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above --T Address Permission is hereby granted to dispose of the human remains described above as indicated. , le Date Issued 06/30/2017 Registrar of Vital Statistics cnbertaCurtis Efectronicaaysigned (signature) ki District Number 5601 Place Glens Falls, New York IA , I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 71 Date of Disposition ?/r J fl Place of Disposition fi.A1 (wreloy.. :,.: (address) (section) (lot number) (grave number) '' 5 Name of Sexton or Person in Charge of Pr mises /��. .,41 { //� (pie se print) Signature �� y/ Title lD t— (over) DOH-1555 (02/2004)