Fagle, Kathleen E Vn(=,NEW YORK STATE DEPARTMENT OF HEALTHVital Records Section Burial - ansit Permit
Name First Middle_ Last Sex
Kathleen Mary- Fagle Female
Date of Death Age ,If Veteran of U.S. Armed Forces
06/23/2016 68 years War or Dates ,✓ l4
# Place of Death Hospital,institution or
., City,MOM XI!O1 X Glens Falls Street Addre 67 Sheridan Street Glens Falls, Ny 12801
t 1 anner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined D Pending
Circumstances Investigation
la Medical Certifier Name Title
Gerald Abess M D
Address
3 Irongate Plaza Glens Falls, N Y 12801
Qj -•th Certificate Filed District Number Register Number,
didaCi r II tiNgE E -Glens Falls - 5601 322
: ❑Burial Date Cemetery or Crematory
06/24/2016 Pine View Crematory
i❑Entombment Address
;ii BCremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or ' Address
f Hold
CO:
Date Point of
Transportation Shipment
G'! by Common Destination
Carrier
Disinterment Date° Cemetery Address .
o ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
`$g 11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
2
ill
Permission is hereby granted to dispose of the human remains described above
aas,indicated.
Date Issued 06/24/2016 Registrar of Vital Statistics W G:,L+1_- W iti-`t� "
(signature)
District Number 5601 Place Glens Falls, u
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii�q Date of Disposition (e/a`X Place of Disposition fkiviiL ` d
2 (address)
111
co
I (section) (lot number) (grave number)
/tsto-/yi
0 Name of Sexton or Person in Charge of Premises 4y .
z (please print)
Signature a Title OfifwfiN
(over)
DOH-1555 (02/2004)