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Burger, Carol «, - # z 31 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Carol Ann Burger Female Date of Death Age If Veteran of U.S. Armed Forces, 03/23/2016 74 years War or Dates > Place of Death Hospital, Institution or W City, TdU(IXKr V311 ( Glens Falls Street Address Glens Falls Hospital a Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending i Circumstances Investigation Li Medical Certifier Name Title Ageel A. Gillani M D Address 102 Park Street Glens Falls, N Y 12801 Death Certificate Filed District Number Register Number City, TXr 7d! IX0( Glens Falls 5601 157 ❑Burial Date Cemetery or Crematory 03/25/2016 Pine View Crematorium ID Entombment Address ©Cremation Queensbury, NY 12804 Date Place Removed Z❑Removal and/or Held and/or 11": Hold O Date Point of ti❑Transportation Shipment G by Common Destination Carrier iiiiii❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Wilcox& Regan Funeral Home 01821 >> Address 11 Alqonkin Street Ticonderoga, N Y Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above • Address C 111 fL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/24/2016 Registrar of Vital Statistics 1 .)"AA,r W" (signatu District Number 5601 Place Glens Falls iV..� `'' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 Iti Date of Disposition_ . race of Disposition 2,04.i &maipti—, 2 (address) 111 tO 3/31 4t/ CC (section) (lot number (grave number) immt Name of Sexton or Person in Charge of Pr ises �� z /� rase prin) fa Signature �/ Title azitilliilret (over) DOH-1555 (02/2004)