Fairley, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marjorie Carol Fairley Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 14, 2015 80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 41 Woodscape Drive
Manner of Death 0Natural Cause III Accident 0 Homicide 0 Suicide n Undetermined r7 Pending
Circumstances Investigation
L Medical Certifier Name Title
Roberta Miller, M.D. Dr.
Address
16 Crimson Oak Court Schenectady, NY 12301
Death Certificate Filed District Number S Re aster Number
City, Town or Village Moreau 9
0 Burial Date Cemetery or Crematory
June 16, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zi ❑ Removal and/or Held
and/or Address
Hold
t' Date Point of
VP
IL Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment- El Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
k` Remains are Shipped, If Other than Above
Address
iIL s
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued_ e,//(o/ C1/�Registrar of Vital Statistics 4,Q,Z _ /lit e(�'�/d-L
(signature)
District Number #5.(;, a Place /0&,J,/) or A 04 PQL,c.-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1)t`nt a..'e ti/ Cd`t or.°Vm
Date of Disposition 06/16/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section (lot number) (grave number)
Name of Sexton or Pers n in arge of Premises 1 i w.044ty -ar,J(0/ ae
/ (please print)
W Signature Title CS'eyn J1 050
(over)
DOH-1555 (02/2004)