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Hayward, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH P �, �� Vital Records Section Burial - Transit Permit Name First Middle Last Sex Kathleen Hayward female Date of Death Age If Veteran of U.S. Armed Forces, 1 1 /1 2/2 01 1 45 War or Dates n/a 14 Place of Death Hospital, Institution or 48 Peck Ave City, Town or Village Glens Falls Street Address ci Manner of Death❑Natural Cause 0 Accident 0 Homicide Ei Suicide ri Undetermined ©Pending in I—I Circumstances Investigation tu Medical Certifier Name Title P Timothy Murphy Coroner Address 52 Haviland Ave, Glens Falls, NY Death Certificate Filed Glens Falls District Number 5601 Register Number City, Town or Village OBurial Date 11 /15/2011 Cemetery or Crematory Pine View Crematory ei❑Entombment Address ®Cremation Queensbury, NY Date Place Removed ❑ Removal and/or Held and/or Address i;;;; Hold O Date Point of Transportation Shipment G0 by Common Destination Carrier Q Disinterment Date Cemetery Address 0 Reinterment Date Cemetery Address Permit Issued to Registration Number 110 Name of Funeral Home Singleton Healy Funeral Home 01596 Address Bay Rd. Oueensbury, NY iiol Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address CC til Permission is hereby granted to dispose of the human remains desc r'bed above as i Wed. igiii Date Issued Registrar of Vital Statistics .4-')` ." -- (signature) District Number Place in:]] I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI " Ct tornnr✓ ▪ Date of Disposition NO jcf 7«`Place of Disposition PIn ��w (address) la 0 CC (section) /) (lot numb (grave number) CI h/ Name of Sexton or Person in Charge Premises rt}toDt-lr t„rtf' + ► (please print) Signature AikTitle CQ C':'Wrk OL (over) DOH-1555 (02/2004)