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Pollock, Jean NEW YORK STATE DEPARTMENT OF HEALTH It 5 9 Vital Records Section ' ;I Burial - Transit Permit Name First Middle Last Sex _"�` Jean K. Pollock Female Date of Death Age If Veteran of U.S. Armed Forces, ' 5 November 2, 2012 76 War or Dates 7 Place of Death Hospital, Institution or City, Town or Village Glens Falls _Street Address Glens Falls Hospital Manner of Death J Natural Cause n Accident ri Homicide El Suicide ri Undetermined n Pending Circumstances Investigation Medical Certifier Name Title David Cunningham, Dr. Address h - 3 Irongate Glens Falls, NY 12801 � Death Certificate Filed District Number Register Number 1: City, Town or Village Glens Falls 5-4/ .513 4 0 Burial Date Ce rf i to r C ato November , 2012 f !N G,(, etAtA9-lat £� Entombment Address I � ©Cremation OHAL CLUj JO ` 9 %0(.1 Place Removed z�a ri Removal Date and/or Held 1 I and/or Hold Address Date Point of tuL Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address in 0Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01079 Address ajil 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human ain escribed a ove as Indic:ted. Registrar of Vital Statistics Date Issued � / 9 12_‘,.—i—) �-C,,. (signature) ti-AP District Number 1 Place 6/F4s / 'Z..0 A PkviK I certify that the remains of the decedent identified above were disposed off in accordance with this permit on: Date of Disposition 11/05/2012 Place of Disposition ' ,,tO,ijJ r�, fifty n (address) 1 (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises a atq( (ple se print) TE-'3'-i Signature Title CR4 m 0iL ` (over) DOH-1555 (02/2004)