Scally, Marlene NEW YORK STATE DEPARTMENT OF HEALTH 1,-4 • Ilk '31
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marlene Beatrice Scally Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 3, 2016 75 War or Dates
Place of Death Hospital, Institution or
la City, Town or Village Hudson Falls Street Address 22 Meadow Road
0 Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending
W Circumstances Investigation
W
Medical Certifier Name Title
Robert H. Beaty, Dr.
Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Hudson Falls . RA
# ❑Burial Date Cemetery or Crematory
September 7, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
43 and/or Address
p Hold
0 Date Point of
▪ ❑Transportation Shipment
• by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Renterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IAddress
Permission is hereby granted to dispose of the human remain escribed above as indicated.
Date Issued S-7•ao lb Registrar of Vital Statistics _ e1
(signature)
District Number 5 7`a6 Place
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
la Date of Disposition 09/07/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
f`-
IZ (section) /1 (lot number) C (grave number)
aUi
Name of Sexton or Person in Charge of Premises ['elf `�t4
ikli-
please print) �
Signaturea Titleazio k
(over)
DOH-1555 (02/2004)