Gover, Marie NEW YORK STATE DEPARTMENT OF HEALTH , ItiK
Vital Records SectionBurial - Transit Permit
"' Name First Middle Last Sex
7 Marie J. Gover Female
, Date of Death Age If Veteran of U.S. Armed Forces,
a May 27, 2014 76 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
kj Manner of Death El Natural Cause 0 Accident Q Homicide Ei Suicide ri Undetermined n Pending
Circumstances Investigation
¢r' Medical Certifier Name Title
Amy Hogan-Moulton, M.D. Dr.
Address
2 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number 5 b0 I Register Number
Ci , Town or Villa.a Glens Falls `-�1
0 Burial bate Cemetery or Crematory
Ma 28, 2014 Pine View Cremato
. 0 Entombment Address
pt,®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
El Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
iPl Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
'_ ry 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.
Date Issued S 1 25,/ill Registrar of Vital Statistics W,J••1
(signature)
41.
District Number 5 &J j Place Gt.Q s `\s , k jJ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/28/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) i (lot number) (grave number)
Name of Sexton or Person 'n Charge of Premises tk.- , Sedaii
� J (please print)
g
Si nature [-� Title at mot
(over)
DOH-1555 (02/2004)