Maille, Marjorie Ruth NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marjorie Ruth Maille Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/03/2021 87 Years War or Dates
F— Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p• Manner of Death MI NaturalCause 0 Accident 0 Homicide 0 Suicide Undetermined 0 Pending
U
Circumstances Investigation
W Medical Certifier Name Title
0 Kasandra Frasier PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 376
0 Burial Date Cemetery,Crematory or Facility Name
09/03/2021 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
Donation
Z ElRemoval Date Place Removed
and/or and/or Held
F— Hold Address
N
0
Date Point of
Cl) L j Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
ElDisinterment
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped,If Other than Above
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/03/2021 Registrar of Vital Statistics W96ertAndrew Curtis(Electronically Signed)
(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:
~ Disposition9�,2oa/ DispositionFi ' � C /
Z Date of Place of e ��� R f
W (addr
W
CC (section) d(Alot numb ) (grave number)
CC
• Name of Sexton or Person in Char a of Premiss ?R 7 A 0")el F. 0 trod
O (please print)
W Signature /�� Title
�' �
DOH-1555(07/18)p 1 of 2
. o.
?JY 51_10
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#