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Morency, Anna NEW YORK STATE DEPARTMENT OF HEALTH t w k it OD Vital Records Section Burial - Transit Permit Name First Middle Last Sex Anna Lucille Morency Female a,=; Date of Death Age If Veteran of U.S. Armed Forces, December 27, 2012 95 War or Dates I Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home Manner of Death n Natural Cause n Accident I I Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title Roslyn Socolof, M.D. Dr. Address 100 Broad Street Glens Falls, NY 12801 Death Certificate Filed District Ner Regis r Number City, Town or Village Fort Edward _ 'j ❑Burial Date Cemetery or Crematory December 31, 2012 Pine View Crematory 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Removal Date Place Removed and/or and/or Held ,FL- Hold Address Date Point of p., n Transportation Shipment tni by Common Destination (3 Carrier nDisinterment Date Cemetery Address Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom -. Remains are Shipped, If Other than Above 2 Address Ix W °' Permission is he by ranted to dispose of the hums ains,describ bove s indicated. Date Issued/ �/ 4.1 _ Registrar of Vital Statis cs „L 4/ -- . (signature) , District Number Place le,Y44--1 FT-, &.‘ �1 -' I certify that the remains of the decedent identified ab a were disposed of in accordance with this permit on: Lail Date of Disposition 12/31/2012 Place of Disposition Quaker Road Queensbury,NY 12804 Z. (address) Ui, (section) / (lot number) (grave number) a` Name of Sexton or Per .n in Charge f Premises A„AI - ci.,+it z (please print) LIJ Signature If. Title Ceffi OL (over) DOH-1555 (02/2004)