Marotta, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH • \ Z/v
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marjorie (Stout) Marotta Female
_' Date of Death Age If Veteran of U.S. Armed Forces,
April 14, 2016 93 War or Dates
Pla e of Death�+ A Hospital, Institution or
11v own or Village )v1Sr-RA4,t,,Street Address River Ridge Living Center
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
w Maximo Valero, Jr. Dr.
Address
Death Certificate Filed District N mb Register N mber
own or Village -�.k �/ ►M-'rkrtr-O �� r: ,
0 Burial Date Cemetery or Crematory
April i q 2016 Pine View Crematory
v.",❑Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
11i_ I I Transportation Shipment
fa by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
: Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
-, Address
Permission is here y,7 anted to dispose of the human re describedlabov la, d; •ted. _ tr1
Date Issued t' ILe Registrar of Vital Statistics -Lv
(signature) &
District Number O I Place �+U c- ) yyk4zP—
I certify that the remains of the decedent identified above were disposed of in a corda�n�cee with this permit on:
04/ 2016QuakeriR Road ueensbu NY 12804
tr Date of Disposition Place of Disposition Q rY,
(address)
£ (section) - w (lot mber) (grave number)
tst
' Name of Sexton or rs i Charge of Premises / E /�t
(please print)
* Signature Title Gres 440/
(over)
DOH-1555 (02/2004)