Rich, Marion NEW YORK STATE DEPARTMENT OF HEALTH '` # 7$7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marion Leona Rich Male
MY- Date of Death Age If Veteran of U.S. Armed Forces,
December 16, 2014 85 War or Dates
Place of Death Hospital, Institution or
`r` City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause El Accident El Homicide n Suicide ri Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Marvin Davidowitz, Dr.
Address
Glens Falls Hopital Glens Falls, NY 12801
Death Certificate Filed District Number �` (� JV Regi ber
V. City, Town or Village Glens Falls lI
Date Cemete or Crematory
❑Burial December 18, 2014 Pine View Creatory
.❑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
by Common Destination
Carrier
Disinterment
Date Cemetery Address
f
Date Cemetery Address
4 Reinterment
5
Permit Issued to Registration Number
.rf Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
41 136 Main Street, South Glens Falls NY 12803
4 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 'ns described above akindicated
Date Issued
Registrar of Vital Statistics
; (signature)
District Number ��, Place � ,- -��fZZ) CZ-C���/ 7
r
i
,,,,,,
,; I certify that the remains of the decedent identified above were di osed of in accordance w' h this permit on:
_ Date of Disposition 12/18/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Perso in Charge f Premises ^ Saottit
(please print)
Signature Title 001 t
(over)
DOH-1555 (02/2004)