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Palmer, Marion NEW YORK STATE DEPARTMENT OF HEALTH ' 14 ft 713 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Marion Louisa Palmer Female Date of Death Age If Veteran of U.S. Armed Forces, May 11, 2013 92 War or Dates I Place of Death Hospital, Institution or W City, Town or Village Argyle Street Address PLEASANT VALLEY NURSING FAC. W, Manner of Death Lurri Natural Cause ElAccident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title W Dr. Edit Masaba, Address McClellan Health System Salem, NY 12865 Death Certificate Filed District Number� Register Nur r City, Town or Village / ❑Burial Date Cemetery or Crematory May 15, 2013 Pine View Crematorium ❑Entombment Address 0 Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address F-- Hold SEELEY CEMETERY CO Date Point of ip ❑Transportation Shipment CO by Common Destination 13 Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom F'.' Remains are Shipped, If Other than Above M Address Ce W. 0.` Permission is h reb granted to dispose of the human 'ns descri e a ove as indicated. Date Issued 3 Registrar of Vital Statistics r ici (signature) District Number 5r-B, Place T ' AD I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 5- 1(1-13 Place of Disposition f?tJ1. �ewcbc,"-- M (address) Ui © (section) 4 (lot number) U (grave number) ca Name of Sexton or Perso n Charge Premises � G' Z / (pl se print) Ui r L" /15,�r►1A'ii+l{.Signature Title (over) DOH-1555 (02/2004)