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Sutliff, Diane NEW YORK STATE DEPARTMENT OF HEALTH ` ‘ 4:1 3 Vital Records Section Burial - Transitermit Name First Middle Last Sex Diane Louise Sutliff Female Date of Death Age If Veteran of U.S. Armed Forces, June 12, 2014 66 War or Dates Place of Death Hospital, Institution or ,: City, Town or Village Kingsbury Street Address 3394 County Route 43 :AL. Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending . Circumstances Investigation _- Medical Certifier Name Title Address i Death Certificate Filed District Number Register Number z, Ci , Town or Village Kingsbury 5 7b a, /a, 0irt Burial Date Cemetery or Crematory June 13 2014 Pine View Cremato 0 Entombment ° Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held and/or Address Hold Date Point of T]Transportation Shipment 1 by Common Destination _ Carrier Disinterment Date Cemetery Address "'Ell Reinterment Date Cemetery Address = Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01079 f. Address 82 Broadway, Fort Edward NY 12828 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 remains described above as indicated. i ( Registrar of Vital Statistics "YF' - fl a Date Issued - 1�-�0 9 CA} (signature) District Number 5-7(Q d, Place `-r.-,..r.. <4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ii Date of Disposition 06/13/2014 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) j (lot numbe (grave number) Name of Sexton or Person in arge of Premises olovoliii 7' (please print) Signature IL" 9� Title (v 4, (over) DOH-1555 (02/2004)