McDougall, Marjorie 1
NEW YORK STATE DEPARTMENT OF HEALTH h' 7 gy
Vital Records Section Burial - Transit Permit
:: Name First Middle Last Sex
Marjorie Louise McDougall Female
Z.
Date of Death Age If Veteran of U.S. Armed Forces,
F' October 29, 2015 73 War or Dates
Place of Death Hospital, Institution or
5 City, Town or Village Argyle Street Address 822 McDougal Road
Manner of Death X❑ Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Max Crossman, M.D. Dr.
Address
65 Poultney Steet Whitehall, NY 12887
Death Certificate Filed District Number Register Number
=,..-
P741 City, Town or Village Argyle D 7$$v S
til❑Burial Date Cemetery or Crematory
November 2, 2015 Pine View Crematory
`-tea❑Entombment Address
# ;®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
`, ❑Transportation Shipment
1. 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-Argyle 01077
Address
123 Main St., Argyle NY 12809
t Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ins
_ describedn above as indicated.
Date Issued (I /a /iS Registrar of Vital Statistics ` -e ,
J (signature)
District Number 5"7 50 Place 1, L I ►.1\.t
,. 4 j J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F Date of Disposition 11/02/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) ,/� (lot number) (grave number)
Name of Sexton or Person in Charge of Premises r!!„ . 5�...ei
/ please print)
Signature Vt- Title «vt11Z
(over)
DOH-1555 (02/2004)