King, Virginia e P.% /V U 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
_vir,Mgi L.King Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/16/2018 72 War or Dates no
Place of Death Hospital, Instituti
City, Town or Village Street Address b 1 b Rte. 9N, Apt 3
Manner of Death® Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Christopher Mason, MD
Address
} Glens Falls Cancer Center,Glens Falls, NY 112801
--: Death Certificate Filed District Number Register Number
City, Town or Village Hadley ,�/s'Se /3
❑Burial Date Cemetery or Crematory
12/20/2018 Pine View Crematory
[I Entombment Address
®Cremation Queensbury, NY
Date Place Removed
El❑Removal and/or Held
_= and/or Address
Hold
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 Brewer Fuenral Home, Inc. 00211
Address
7, 24 Church St., Lake Luzerne, NY 12846
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 remai described above as indicated.
Date Issued 12/18/2018 Registrar of Vital Statistics
�4,,�,.
(signature)
District Number y ? Place Hadley, NY
.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition i a-a0-Ik Place of Disposition 'Pi t V.'t.w Cr,rvti.0r.,r`
zF_ (address)
(section) i (l�jt number) (grave number)
Name of Sexton or Person in Charge of Premises M, c_`,hi_( I5/wni I4
/Z— cre
(please print)
Signature
Title ^`p4e
(over)
DOH-1555 (02/2004)