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Morrill, Ann f 52Z NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit y` Name First Middle Last Sex Ann Marie Morrill Female Date of Death Age If Veteran of U.S. Armed Forces, July 24, 2016 65 War or Dates Place of Death Hospital, Institution or w City, Town or Village Glens Falls Street Address Glens Falls Hospital et Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined 1-7"—I Pending ILI CircumstancesInvestigation g. Medical Certifier Name Title Darci Ann Gaiotti-Grubbs, M.D Dr. Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number ay-)1 Registe- City, Town or Village Glens Falls , ! > ;_❑Burial Date Cemetery or Crematory July 29, 2016 Pine View Crematory ❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold g Date Point of ❑Transportation Shipment II by Common Destination a Carrier ❑ Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address iii Permission is hereby granted to dispose of the human r mains scribed bove as in• • -•. Date Issued Registrar of Vital Statistics `Z-i—e -c- - ' (signature) District Number_5/©7 Place /— f I certify that the remains of the decedent identified above were disposed of in ccordance with this permit on: Date of Disposition 07/2' l2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) anItpL- (lot number) (grave number) Name of Sexton or Person in Charge of Premises Signature S� j a � (Neese print) nature �� Title 9 (over) DOH-1555 (02/2004)