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Doroski, Patricia NEW YORK STATE DEPARTMENT OF HEALTH 4 311 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Patricia Ann Doroski Female Date of Death Age If Veteran of U.S. Armed Forces, May 14, 2014 70 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Natural Cause 0 Accident D Homicide 0 Suicide 0Undetermined � Pending Circumstances Investigation Medical Certifier Name Title Michael Adams, Dr. Address ii a 10154 Saratoga Raod Fort Edward, NY 12828 Death Certificate Filed District Number j. Register Number City, Town or Village Glens Falls 5 U 01 2 32. 0 Burial Date Cemetery or Crematory May 16, 2014 Pine View Crematory ,u Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address I i= Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01079 Address 82 Broadway, Fort Edward NY 12828 tei 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 .5 / / 6 ( J y Registrar of Vital Statistics W° ' W (signature) District Number 5�© � Place 6 lQM ‘\S / VV I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 05/16/2014 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) diso.. (lot number) (grave number) Name of Sexton or P son in Ch ge of Premises ` 4/ / (please print) Signature ` L Title <<� hort 9 �' Ve (over) DOH-1555 (02/2004)