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Bengle, Delores Ernestine NEW YORKSTATE DEPARTMENT OF HEALTH - Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Delores Ernestine Bengle Female Date of Death Age If Veteran of U.S.Armed Forces, 03/22/2021 76 Years War or Dates __ Place of Death Hospital,Institution or W' City,Town or Village Argyle Town Street Address 164 Coach Road,Argyle Town,New York 12809 0 Manner of Death © Natural Cause El Accident 1=I Homicide El Suicide 0 Undetermined ❑Pending ILI Circumstances Investigation 1, Medical Certifier Name Title Ashley Watson NP Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Argyle 5750 23 ElBurial Date Cemetery,Crematory or Facility Name 03/23/2021 Pine View Crematory El Entombment Address wCremation Queensbury Town,New York z Li Donation Z 0 Removal Date Place Removed and/or and/or Held rij Hold Address 0 a Date Point of UJ) Li Transportation 5by Common Shipment Carrier Destination Disinterment Date Cemetery Address 11 Reinterment 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 I-. Remains are Shipped,If Other than Above 2 Address CIC Ci" Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/23/2021 Registrar of Vital Statistics She(Cey!Mclgrnon(ECectronicaltySigned) (signature) District Number 5750 Place Argyle, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: / 10. Date of Disposition ��75 Ili Place of Disposition �� 2 (address) W CO C' (section) (lot number) (grave number) irr 0 Name of Sexton or Person in Charge of Premi 1 n I` \ ,,� Z (P/ Print/ Signature 0Title re041'r DOH-1555(07/18)p 1 of 2 t Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on - , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#