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Crowe, Hume tt NEW YORK STATE DEPA 'TMENT OF HEALTH ��� Vital Records Section ` . Burial - Transit Permit Name First Middle Last Sex Hume Crowe M Date of Death Age If Veteran of U.S. Armed Forces, 06/06/2014 92 War or Dates 1- Place of Death Hospital, Institution or 5 City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause El Accident El Homicide El Suicide ❑Undetermined ❑Pending tLiCircumstances Investigation u Medical Certifier Name Title p Dean Reali DO Address 100 Park Street Glens Falls, NY 12801 ' Death Certificate Filed District Number tom, G_(`1 Regist``'( l City, Town or Village Glens Falls ❑Burial Date Cemetery or Crematory 06/09/2014 Pineview Crematory Entombment Address ®Cremation 21 Quaker Road, Queensbury,NY 12804 Date Place Removed ❑Removal and/or Held and/or Address f= Hold CA 0 Date Point of " Transportation Shipment t a by Common Destination Carrier ❑Disinterment Date _ Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home MB Kilmer Funeral Home 01 079 Address 82 Broadway, Fort Edward,NY 12828 Name of Funeral Firm Making Disposition or to Whom - Remains are Shipped, If Other than Above Address 0 I ` Permission is hereby granted to dispose of the human remains de rib! a ve a J d' ated. Date Issued OCA/ �/ Registrar of Vital Statistics G G� Gz (signature) gi District Number O/ Place ��� /xi/i ,yV I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 ILI Date of Disposition 6_ - IO-19 Place of Disposition V„uU,. ,,J ergot,,,,., (address) In 0 CC (section) A (Lot numb ) (grave number) CI Name of Sexton or Person i Charge of Premises Uhh f (please iiiHi Signature Title (over) DOH-1555 (02/2004)