Gibson, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Louise Gibson Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/20/2018 83 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death®Natural Cause El Accident El Homicide ID Suicide ElUndetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Scott Biasetti MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
01/24/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
El Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reintemtent Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
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 remains described above as indicated.
Date Issued 01/24/2018 Registrar of Vital Statistics cgbertA Curtis(E(ectronica1CySignedt)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1-25-/j Place of Disposition / /»Q ) ) E .44,
(address) '
(section) (lot number) (grave number)
Name of Sexton or a on "nCharge of Premises ' ` ��� t2ant /Ai-.y
(please print)
2�� Title y2fV1Gi. '
Signature
(over)
DOH-1555(02/2004)