Pollock, Marion 645
NEW YORK STATE DEPARTMENT OF HEALtTH-,
Vital Records Section y Burial - Transit Permit
Name First Middle Last Sex
Marion J. Pollock Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/18/2013 82 years War or Dates
}- Place of Death Hospital, Institution or
5 City, Towli /ifXX Glens Falls Street Address Glens Falls Hospital
0 Manner of Death N natural Cause 0 Accident 0 Homicide El Suicide 0 Undetermined ri Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Sean Bain M D
Address
100 Park St. Glens Falls, N Y
Death Certificate Filed District Number Register Number
:. City, Tow X Glens Falls 5601 438
El Burial Date Cemetery or Crematory
❑Entombment Address10/21/20;3 Pine View Cemetery
n Cremation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
9. and/or Address
F_ Hold
67
Cy Date Point of
05 0 Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home, Inc. 00448
Address
7 Sherman Ave. Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
.1 Remains are Shipped, If Other than Above
2 Address
!t
Lu
` Permission is hereby granted to dispose of the human remains described ab ve a icated.
Date Issued 10/21/2013 Registrar of Vital Statistics X' t/
(signature)
District Number 5601 Place Glens Falls
I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
la Date of Disposition to(Ltb Place of Dispositiongattos actor-A--
2 (address)
la
to
ir (section) 4(lot number) (grave number)
0
ct Name of Sexton or Person in harge of Pr mises _ ,,,ti ►.Jt
(pl se print)
ig
Signature Title Cc M
(over)
DOH-1555 (02/2004)