Dingman, Ann Daly (.F t 503
NEW YORK STATE DEPARTMENT OF HEALTH '� Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ann Daly Dingman Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/20/2022 93 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 311 West Mountain Road,Queensbury Town,New York 12804
ILI
pManner of Death ❑X I Natural Cause Accident (Homicide Suicide nUndetermined ❑Pending
0 Circumstances Investigation
LU Medical Certifier Name Title
CI Aimee Mcmaster Nurse Practitioner,Acute Care
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 101
Burial Date Cemetery,Crematory or Facility Name
06/21/2022 Pine View Crematory
nEntombment Address
li1Cremation Queensbury Town,New York
Donation
Z❑Removal and/or Date Place Removed
and/or Held
H Hold Address
U)
0
tL Date Point of
U)nTransportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
nDisinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
p— Remains are Shipped,If Other than Above
I- Address
Cr
LU
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/21/2022 Registrar of Vital Statistics Caroline 7fiCcfegarde(Barber(Electronically Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH `
Z Date of Disposition !�—12 7p22lace of Disposition ?I ,'e Vi� ) £end l , .
2 (address) ��
W
U)
CC (section) f a (lot nun, r) (grave number)
0
Name of Sexton or Person in Charge of emise �4 1110.4 b 0Q d
Z /p! se print/
W Signature Title QeL
4-
DO H-1555(07/18)p 1 of 2
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# \:..