Gage, Mary Carolyn it /2
NEW YORK STATE DEPARTMENT OF HEALTH - ` L, � _
Bureau of Vital Records __ : Burial Transit Permit
Name First Middle Last Sex
Mary Carolyn Gage Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/30/2023 86 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 198 Burt Road,Moreau Town,New York 12828
`p Manner of Death El Natural Cause Accident Homicide ESuicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Aimee Mcmaster NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 1
Burial Date Cemetery,Crematory or Facility Name
01/02/2024 Pine View Crematory
Entombment Address
®Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
Hold Address
0
d Date Point of
U)DTransportation
Q by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
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
1— Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/02/2024 Registrar of Vital Statistics Brenda Jfutter(E(ectronica(Cy Signed)
(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 113)2 9 Place of Disposition f'sucr'EJ Cr4E., 41vt2-14/....
2 (address)
W
CC N
(section) 4,,.(lot number) (grave number)
Name of Sexton or Person in Charge of Premises M�— c'^�t�}
(=::/e
(p ase print)
Z /
W Signature Title ( Mq�2
DOH-1555(07/18)p id 2
01,7806
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#