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Fearis, Barbara NEW YORK STATE DEPARTMENT OF HEALTH • i u Vital Records Section Burial - Transit Permit Name First Middle Last Sex Barbara Ann Fearis Female Nivw Date of Death Age If Veteran of U.S. Armed Forces, ws November 6, 2013 66 War or Dates Place of Death Hospital, Institution or City, Town or Village Street Address 2905 County Rt. 46 Manner of Death ❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Darci Ann Gaiotti-Grubbs, M.D Dr. Address kw E 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Regis er/Number City, Town or Village 5-25:s Cv 0 Burial Date Cemetery or Crematory 44 November 7, 2013 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 ❑ Removal Date Place Removed and/or and/or Held Hold Address Date Point of ❑Transportation Shipment ¶, _ by Common Destination Carrier ❑ Disinterment Date Cemetery Address j Date Cemetery Address ❑ Reinterment ttli Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01079 ,;41i Address 82 Broadway, Fort Edward NY 12828 A Name of Funeral Firm Making Disposition or to Whom . Remains are Shipped, If Other than Above Address Permission is he by ranted to dispose of the human r ains descri ed a ve as indicated. 40- Date Issued Registrar of Vital Statistic 20 p (sign ure) District Numbers 7] 5 Place /6)1.4),-) 3 . �-1--- CrI; a / I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 11/07/2013 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) 4(lot number) (.` (grave number) Name of Sexton or Person i Charge of remises !l,.:s1 ,- N1104) (pl ase print) Signature °D\- Title (fZenl►9�t�_ :T It (over) DOH-1555 (02/2004)