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Newell, Constance 4-4 ( 7 NEW YORK STATE DEPARTMENT OF HEALTH _ Vital Records Section I. , Burial - Transit Permit APName First Middle Last Sex Constance Newell Female Date of Death Age If Veteran of U.S. Armed Forces, January 27, 2013 55 War or Dates Place of Death Hospital, Institution or uf City, Town or Village Street Address Saratoga Hospital Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation II,, Medical Certifier Name Title e°, Michael Sikirica, Address 50 Broad Street Waterford, NY 12188 Death Certificate Filed District Number Register Number I City, Town or Village Pt. z,❑Burial Date Cemetery or Crematory February 4, 2013 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Removal Date Place Removed and/or and/or Held ` Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number tie Name of Funeral Home M.B. Kilmer Funeral Home 01078 ! Address w�. 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above '�• Address tli Permission is h reby ranted to dispose of the human remain escr Mrlooverp ' icated. Date Issued t ZQ' 206 Registrar of Vital Statistics (signature) District Number W Hai Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 02/04/2013 p Place of Disposition Quaker Road Queensbury,NY 12804 (address) I (section) number) R (grave number) Name of Sexton Per • Charge of Premises p Signature / 1 4163- (please print) Title 0¢ s d6C— O- (over) DOH-1555 (02/2004)