Whipple, Monigue Ann NEW YORK STATE DEPARTMENT OF HEALTH L—FBurial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Monique Ann Whipple Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/30/2023 59 Years War or Dates
l~ Place of Death Hospital,Institution or
W City,Town or Village Moreau Town Street Address 103 Feeder Dam Road,Moreau Town,New York 12803
❑ Manner of Death El Natural Cause Accident ❑Homicide OSuicide ElUndetermined ❑Pending
W
U f� ((Circumstances Investigation
W Medical Certifier Name Title
0 Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 33
Burial Date Cemetery,Crematory or Facility Name
07/03/2023 Pine View Crematory
Entombment Address
nCremation Queensbury Town,New York
Donation
Date Place Removed
0❑Removal
- and/or and/or Held
H- Hold Address
N
0
d Date Point of
N Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
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
1— Remains are Shipped,If Other than Above
5' Address
CC
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/01/2023 Registrar of Vital Statistics Brendalfutter(EYctravricallySOrtea)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /�
Z Date of Disposition 713 I73 Place of Disposition fL G.�10"--^
LU (address)
W
0 d
(lot nu berg^ (grave number)
(section) \�r�
❑ Name of Sexton or Person in Charge of Premises r' ' t
(base print)
U.1
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Signature Title (Pic/ 44Toa
DOH-1555(07/18)p 1 of 2
i i ' ' <
1 Public Health Law Sec. 4145(2b)
7
1
Receipt
Human remains of delivered on , 20
I
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#