Gillingham, Marilyn NEW YORK STATE DEPARTMENT OF HEALTH ` 400�° t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marilyn J. Gillingham Female
Date of Death Age If Veteran of U.S.Armed Forces,
*'`` October 22,2014 72 War or Dates
Place of Death Hospital, Institution or
Z; City, Town or Village Queensbury Street Address Westmount Health Care Facility
0: Manner of Death
X Natural Cause Accident � +Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
14 Manor Drive,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
: City, Town or Village Queensbury 5657 136-
❑Burial Date Cemetery or Crematory
❑Entombment October 24,2014 Pine View Crematory
Address
CI Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
OLi Removal and/or Held
and/or Address
Hold
Cl)
0 _ Date Point of
CI. _Transportation Shipment
by Common Destination
_ Carrier
ri Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
v.s Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
4 3809 Main Street,Warrensburg,NY 12885
°,a. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
e
,,,„
,,-- Permission is hereby granted to dispose of the human rema' s cri a ndic ed.
Date Issued 10-24-14 Registrar of Vital Statistics CAA_
y :ii
(signature)
a Ditit Numb srcNumber Place
s 5657 Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II—
Date of Disposition 1o!2-ij/y Place of Disposition �ti£se V Ciyw'br,-
W (address)
CO
0 (section) tot number
O ( (grave number)
p Name of Sexton or Person in Charge of Premises ,r,,.� awU
Z tl (P ase print)
Signature Title their
rot
(over)
DOH-1555 (02/2004)