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Goodspeed, Annamae t # 503 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit • Name First Middle Last Sex Annamae Goodspeed Female Date of Death Age If Veteran of U.S.Armed Forces, • 06/29/2017 86 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Undetermined Pending ©Natural Cause �Accident �Homicide �Suicide [] � Circumstances Investigation • Medical Certifier Name Title Mathew Varughese DO Address 100 Park St,Glens Falls,New York 12801 • Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 358 OBurial Date Cemetery or Crematory 07/03/2017 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed Removal and/or Held and/or Address Hold Date Point of t` Q Transportation Shipment by Common Destination Carrier fr,4$IDDisinterment Date Cemetery Address 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 Address 1 .1 Permission is hereby granted to dispose of the human remains described above as indicated. • Date Issued 06/30/2017 Registrar of Vital Statistics gZp6ert ACurtis ECectronica1TySigned (signature) 11- District Number 5601 Place Glens Falls, New York • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 7 13 in Place of Disposition f?,40� CR"^ ''^" (address) —'IMal i (section) (lot number) ,y� (grave number) Name of Sexton or Person in Charge ofPremises G/l� 1— S '�/ (pleas print) Signature b Title Cefil4etrt, (over) DOH-1555(02/2004)