Dick, Marion fr cica
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marion J. Dick Female
Date of Death Age If Veteran of U.S. Armed Forces,
Sept. 5, 2011 93 War or Dates No
#- Place of Death Tn. of Northumberland Hospital, Institution or 3 Railroad Ave.
X City, Town or Village Street Address
Ili
Manner of Death Undetermined Pending
1u Circumstances Investigation
iii Medical Certifier Name Title
Jospeh C. Mihindu MD
Address
70 Murray St. Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City, Town or VillageTn. of Northumberland
❑Burial Date Cemetery or Crematory
Sept. 12, 2011 Pine View Crematory
❑Entombment Address
®Cremation 21 Ouaker rzon(3 Ouo nsbury, N2`W York
Date Place Removed
ZRemoval and/or Held
2❑and/or Address
02)
• Hold
O Date Point of
n'`0 Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
.- _ Reinterment Date Cemetery Address
i:i:;:
Permit Issued to Registration Number
Name of Funeral Home M• :3. Kilmer ?u ne ra l dome 01 078
Address
135 Main St. South Glen;, 'Pri11:;, Nr,tv York 12303
,:: Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
2 Address
IX
tii
Permission is hereby granted to dispose of the human remains described above as indicated. �
Date Issued C�ln'1 la0 li Registrar of Vital Statistics21LQ-rru !l
(signature)
District Number t C Place ;0 Lon o Nrd v u rn1,,e v ` �Y
I certify that the remains of the decedent identified above were disposedn of in accordance with this permit on:
tii Date of Disposition 11( 1(i Place of Disposition xingtNw egritcfortut.
2 (address)
wail
U)
iM (section) (lot numb (grave number)
Ct tt Name of Sexton or Per on in Char of Premises (I S 1/4)e.,46,—
r (please print)
Signature Title C%_nk.��Ut
(over)
DOH-1555 (02/2004)