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Simonson, Barbara NEW YORK STATE DEPARTMENT OF HEALTH Ilk l '3,to Vital Records Section f Burial - Transit Permit Name First Middle Last Sex Babara L. Simonson Female Date of Death Age If Veteran of U.S.Armed Forces, 1. July 26, 2012 70 War or Dates no Z Place of Death Hospital, Institution or W City,Town,or Village Glens Falls Street Address Glens Falls Hospital 0 Manner of Death © Natural Cause ❑Accident 0 Homicide 0Suicide n Undetermined ❑ Pending W Circumstances Investigation 0 Medical Certifier Name Title 1l1 Heidi Rasmusson MD 0 Address 65 Poultney Street Whitehall New York 12887 Death Certificate Filed District Numb J' Registsyl�lumkyer'� City,Town or Village Glens Falls L �� El Date Cemeteryor Crematory Burial July 31, 2012 ine View Creatorium ❑Entombment Address ®Cremation Town of Queensbury Date Place Removed 0 E Removal and/or Held - and/or Address Hold 0 Date Point of 0 El Transportation Shipment C. by Common Destination 0Carrier - Date Cemetery Address 5 ❑ Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Jillson Funeral Home, Inc. 00885 Address 46 Williams Street, Whitehall, New York 12887 ~ Name of Funeral Firm Making Disposition or to Whom 2 Remains are Shipped, If Other than Above W Address O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 71 3 0 //2 Registrar of Vital Statistics t. cA (sign t�ure) District Number 5 6© ` Place Glens Falls,New York F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z {,� tDate of Disposition g-i-11 Place of Disposition 'fLU kJ Ch„it4r io... 2 (address) +n it (section )( ) � Opt number) (grave number) iName of Sexton or Person in Charge of remises l,� Sitytit W (pl ase print) Signature C Title CiyEyrtr}tpQ (over) DOH-1555 (02/2004)