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Carmen, Lorraine NEW YORK STATE DEPARTMENT OF HEALTH c Vital Records Section Burial - TransitQrmit • c Name First Middle Last Sex Lorraine Carmen Female Date of Death Age If Veteran of U.S. Armed Forces, December 6, 2013 85 War or Dates Place of Death Hospital, Institution or L City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home Manner of Death Iv, E.i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Philip J. Gara, Dr. Address 318 Broadway Fort Edward 12828 }- Death Certificate Filed District Number Register umber Ci , Town or Village Fort Edward .5'7Ts---- 7 ❑Burial Date Cemetery or Crematory December 10, 2013 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held 2�y and/or Address • Hold #ter Date Point of ❑Transportation Shipment by Common Destination • Carrier • Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address 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 Address i Permission is her y anted to dispose of the human ins descri e abov as indica ed. d t Date Issue / �g Registrar of Vital Statisti ��� i (signatu - /��- District Number�z$. Place j0�y-, ce"� I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 12/10/2013 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) ,/(lot number) (grave number) Name of Sexton or Person i Charge of Pr mises lls-4 -- o4nll4 (plebse print) Signature Title C16 iUK (over) DOH-1555 (02/2004)