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Boucher, Cathleen Patricia . ..: 4. 0 r NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle last Sex Female Cathleen Patricia Boucher Date of Death Age If Veteran of U.S.Armed Forces, 09/23/2021 81 Years War or Dates . Place of Death Hospital,Institution or WCity,Town or Village Granville village Street Address Granville Center for Rehabilitation and Nursing O Manner of Death ©Natural Cause 0Accident Homicide n Suicide n Undetermined 0 Pending Circumstances Investie�ation WI Medical Certifier Name Title O Shardul Kopper DO Address 17 Madison St.Granville Village.New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville Villa a 5725 47 0 Burial Date Cemetery,Crematory or Facility Name 09/24/2021 Pine View Crematory LiEntombment Address LICremation Oueensbury Town,New York • nDonation ❑Removal Date Place Removed and/or and/or Held ~ Hold Address d1 Date Point of H �Transportation Shipment a by Common Carrier Destination Date Cemetery Address Disinterment • Date Cemetery Address riReinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Fella 01078 Address 136 Main St,S Glens Falls.New York 12803 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 5 Address cc AU a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/24/2021 Registrar of Vital Statistics clwrd p6erts('E(ectrontca((y Signed) , (signature) District Number 5725 Place Grenville Village. New York I certify that the remains of the decedent identified above were disposed of in accordance with this on: WDate of Disposition -125 z Z f Place of Disposition PI A ut'QbQ (.-r L/de i.,- lif (address) ILI I / (sealon (lot number) (grave number) Name of Sexton or Person in Charge Premises // .4d W l'D� (please print) ILI e �/.7 Title Signature `� �� ' DOH-1555(07/18)p tot 2 TO 390d d3W1IAOW BbSLLbLBTS OC:TZ TZOZ/EZ/60 x I) "o a.., .g_. Public Health Law Sec. 4145(2b) Receipt Human remains of G _delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#