Dutcher, Mary Arlene , , 4 tol
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Arlene Dutcher Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/30/2023 91 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
pManner of Death Q Natural Cause Accident El HomicideSuicide ElUndetermined Pending
Circumstances Investigation
0 Medical Certifier Name Title
John Quaresima MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
Cit ,Town or Village 5755 14
Burial Date Cemetery,Crematory or Facility Name
02/01/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
ZOā¯‘Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
tL Date Point of
CO 0Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
LiReinterment Date Cemetery Address
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
l- Remains are Shipped,If Other than Above
2 Address
CC
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/31/2023 Registrar of Vital Statistics ,3mte8G.9faleoney(Electronica/JSigned)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZW Date of Disposition 213)73 Place of Disposition -t7...ILz-----
2 (address)
W
U)
tr (section) (lot number) (grave number)
SName of Sexton or Person in Cha f Premises /^ L,
lease print)
Z
W Signature Title ri '/pe
DOH-1555(07/18)p 1 of 2
016658
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#