VanDyke, Marilyn NEW YORK STATE DEPARTMENT OF HEALTH LF Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marilyn VanDyke Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/13/2023 92 Years War or Dates
F Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
p Manner of Death I I Natural Cause nAccident I I Homicide nSuicide Undetermined Pending
uj f
U Circumstances Investigation
LU Medical Certifier Name Title
0 Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 139
Burial Date Cemetery,Crematory or Facility Name
05/05/2023 Friends Cemetery
Entombment Address
Cremation Queensbury Town,New York
Donation ,
Z❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
tO
0
d Date Point of
U) Transportation Shipment
Q by Common
Carrier Destination
O
Disinterment
Date Cemetery Address
Date Cemetery Address
0 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
Il— Remains are Shipped,If Other than Above
S' Address
CC
LU
Q. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/15/2023 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H �('�
Z Date of Disposition rj,_`j. ;,�3 Place of Disposition C[j�i el k - -1 cCCc�(a des 1e.e �� , )y, 1
NCC �i/ n •5 /1 (lo /er) (grave number)
S Name of Sexton or Person in Charge of Premi ( ..cmt7n i cTCk
(pleas print)
Z p
W Signature AgA;/_ ,C.. i Title .J1i17C.T 11) n
DOH-1555 07/18)p t of 2
Public Health Law Sec. 4145(2b)
012979
Receipt
Human remains of delivered on r'` �' , 20 .„3
fwr;
Pit a fView Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# -
VANDYKE (LF
NAME Marilyn VanDyke Age: 92
Lot Owner: VanDyke Family Plot
Lot# Family Plot Grave# Next to H
Husband
Case: Concrete
Died: 3 .1 3 .2 3 Interred: 5 .5.2 3
Funeral Home: M.B. Kilmer FH
Cemetery: A Q; C� ,�