Powers, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH ' 319
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marjorie Jane Powers Female
'> Date of Death Age If Veteran of U.S. Armed Forces,
05/02/2015 89 years War or Dates
H Place of Death Hospital, Institution or
W City, ToltXXXVD X Glens Falls Street Address Glens Falls Hospital
p Manner of Death gNatural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
Michael Fuller M D
Address
• 100 Park Street, Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, ToiriXXXVIDWIX Glens Falls 5601 237
['Burial Date Cemetery or Crematory
05/06/2015 Pineview Crematory
• a:! ❑Entombment Address
R remation Queensbury, N Y 12804
Date Place Removed
Z Removal and/or Held
P ❑and/or Address�
CA
Hold
0 Date Point of
•
lk❑Transportation Shipment
a by Common Destination
gii Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Rii Permit Issued to • Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
>_ Address
Schroon Lake, N Y 12870
Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, If Other than Above
,'; Address
I •
l
` Permission is hereby granted to dispose of the hum remains described above a indi ated.
Hp Date Issued 05/06/2015 Registrar of Vital Statistics ��1_e4-, '7 /
(signature)
iig District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition c iti if Place of Disposition ,Rt.ik► ( e n
wla
2 (address)
til
jC (section) /j (loot number) (grave number)
474
Name of Sexton or Person in Charge of Premises ` ''' - �4
(please print)
ILI
Signature Title F 'i°fi
12
(over)
•
DOH-1555 (02/2004)