Gregory, Cathleen #-fS
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ' __ Burial - Transit Permit
__,
;:,- Name First Middle Last Sex
Cathleen Mary Gregory Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 28, 2016 62 War or Dates
Place of Death _ i( Hospital, Institution or
City, Town or Village S Street Address Gateway House of Peace
Manner of Death Natural Cause 0 Accident 0 Homicide El Suicide El Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Charles Yun,
;!- Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or VillageLi'd l 05
❑Burial Date Cemetery or Crematory
February 1, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
j and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
,' Date Cemetery Address
Reinterment
cr t. Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
:= Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
=. Address
Permission is hereb granted to dispose of the human ins descr' boy ' 'c .
Date Issued a, 11 I Registrar of Vital Statis .cs
(signature)
District Number'5b \ Place (1 A�Z�(-)
i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/01/2016 Place of Disposition Quaker Road Queensbury,NY 12804 ;y,�,V,¢,i,�f
(address) 1
(section) (lot number) (grave number)
° Name of Sexton or Person in Charge of Premises_ %.te,,p4e/Y Ste:fc,s
(please print)
r Signature �i_ :> Title Lre.
(over)
DOH-1555 (02/2004)