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Quaresima, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH if 19 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Dorothy Margaret Quaresima Female Date of Death Age If Veteran of U.S. Armed Forces, April 8, 2011 88 War or Dates World War II Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Deathm j Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title James North, M.D. Dr. Address Broad Street Glens Fallls 12801 Death Certificate Filed District Number Register Number City, Town or Village 5601 / ❑Burial Date Cemetery or Crematory April 11, 2011 Pine View ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Removal Date Place Removed ❑ and/or and/or Held Hold Address Date Point of ❑Transportation Shipment 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 01097 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 � wk Address Permission is hereby granted to dispose of the human remains described above as indicated. Pryer Registrar of Vital Statistics l� W.` Date Issued c�/ � ► / % i (signature) { District Number 5601 Place f.�/r°/7J cu//.I;,Cif A 0/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 04/11/2011 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot net er) (grave number) Name of Sexton or P son in Charg of Premises a rtst„Q{�t r t,nnlf� 1 (please print) Signature 7'1/IL Title (please (over) DOH-1555 (02/2004)