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Cavanaugh, Mary Metcalfe ©Fl NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Female Mary Metcalfe Cavanaugh Date of Death Age If Veteran of U.S.Armed Forces, 03/07/2023 80 Years War or Dates i_ Place of Death Hospital,Institution or . Z City,Town or Village Fort Ann Town Street Address 228 Hadlock Pond Road,Fort Ann Town, New York 12827 w Manner of Death Undetermined Pending 0 IS]Natural Cause �Ac<ident Homicide Suicide W Circumstances Investigation U Title W Medical Certifier Name CI David Foote MD Address 340A Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed Town Of Fort Ann District Number Register Number City,Town or Village 5754 5 Burial Date Cemetery,Crematory or Facility Name Min 03/08/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York DDonation ZZ❑Removal Date Place Removed and/or and/or Held ~ Hold Address N 0 Date Point of Cl)❑Transportation Shipment p by Common Carrier Destination El Disinterment Date Cemetery Address El Reinterment 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 I... Remains are Shipped,If Other than Above % Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/07/2023 Registrar of Vital Statistics iMiranda Lferringshaw(ECectronicaC(y Signed) (signature) District Number 5754 Place Town Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— y'--. Z Date of Disposition 3 J g I t3 Place of Disposition r1 LU /address)LI LU N (section) (lot number) (grave number) CC 0 Name of Sexton or Person in Charge of Prem. s " n �' tt zolease print) Z ri?r/ �? UJ Signature Title DOH-1555(07/18)p 1 of 2 I 1 f 7 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#