Durham, Irene OQa® ! y
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Male Last Sex
Irene E. Durham Female
Date of Death Age If Veteran of U.S.Armed Forces,
F January 4, 2006 78 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Fort Edward Street Address Own Home
0 Manner of Death E Natural Cause in Accident n Homicide 0 Suicide El Undetermined E Pending
W Circumstances Investigation
G Medical Certifier Name Title
W Dr. Philip J. Gara Dr.
Q Address
318 Broadway, Fort Edward, NY 12828
Death Certificate Filed District Number 3-7� RegisterNumber
City,Town or Village Fort Edward .L�
❑Burial Date Cemetery or Crematory
January 6, 2006 Pine View Crematory
❑Entombment Address
Z▪ El Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
4 n Removal and/or Held
▪ and/or Address
1°' Hold
0 Date Point of
4 0 Transportation Shipment
d by Common Destination
1 Carrier
Date Cemetery Address
Q0 Disinterment
EReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01142
Address
82 Broadway, Fort Edward, New York 12828
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
O.
Permission is hereby granted to dispose of the human remai described ove as indicated.
Date Issued /f6 a00 Registrar of Vital Statisti
(signature)
District Number �7aV Place Fort Edward,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
UI• Date of Disposition 01/06/2006 Place of Disposition Pine View Crematory
(address)
111
, Tel i 1 k Pi L=4) CAZE2vi -ir)1 Zt, U
0 (section) (lot number) r (grave number)
C Name of Sexton or Person in Charge of Premises (�14 (2—v(. �ONN41. N
(please print)
W Title Ci i Ext v .---"d II
Signature
(over)
DOH-1555 (02/2004)