McDougall, Shirley NEW YORK STATE DEPARTMENT OF HEALTH. . _.t 4 Zl
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
",,` Shirley M. McDougall Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 10, 2016 71 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address 169 Hinds Road
Manner of Death X❑ Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
E Circumstances Investigation
Medical Certifier Name Title
Darci Ann Gaiotti-Grubbs, M.D Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Argyle 15 C341
El Burial Date Cemetery or Crematory
January 11, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
. Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
`:;❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
# r
❑ Reinterment Date Cemetery Address
j Permit Issued to Registration Number
F_ Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
R Address
_' 123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address ..m.
Permission is hereby granted to dispose of the human rem ' s described above as indicated.
Date Issued hi I o l v Registrar of Vital Statistics `'1 K-e .
1 (signature)
District Number S-,Sv Place 5 )1,, h
ki
a I certify that the remains of the decedent iderirrabove were disposed of in accordance with this permit on:
Date of Disposition 01/11/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /! (lot number) (grave number)
-•' Name of Sexton or Person in Char a of Premises G`1.,1 "
' please print)
4 Signature Title F 'L
(over)
DOH-1555 (02/2004)