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Russell, Alice NEW YORK STATE DEPARTMENT OF HEALTH ', It Vital Records Section Burial - Transit 1 `Fermi t :=A Name First Middle Last Sex g Alice Russell Female Date of Death Ag91, If Veteran of U.S. Armed Forces, July 22, 2014 / 1 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death 0 Natural Cause ❑ Accident n Homicide 0 Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title . David Foote, Dr. .- Address 4,6 340 Main St. Hudson Falls, NY 12839 Death Certificate Filed District Number ��© ' Register Number '_ City, Town or Village Glens Falls ";❑Burial Date Cemetery or Crematory July 23, 2014 Pine View Crematory ❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed { } ❑ Removal and/or Held and/or Address Hold Date Point of 0 Transportation Shipment =r: 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 01079 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. t Date Issued 7 / z3 nil Registrar of Vital Statistics t� �i; xr (signature) District Number 5 bo` Place $ \V> t N I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 07/ /2014 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) ,, � � (lot number) (grave number) : Name of Sexton Per n in rge of Premises Li i-1 (please print) A_ Signatur Title ( if (over) DOH-1555 (02/2004)