Green, Althea NEW YORK STATE DEPARTMENT OF HEALTH
'*Vital Records Section - -Burial Transit Permit
Name First Middle Last Sex
Althea H. Green Female
Date of Death Age If Veteran of U.S.Armed Forces,
I. December 12, 2006 88 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village South Glens Falls Street Address Own Home
D Manner of Death 0 Natural Cause ❑Accident ❑ Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
O Medical Certifier Name Title
W Dr. Michael Adams Dr.
0 Address
10154 Saratoga Raod, Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
City,Town or Village South Glens Falls
0 Burial Date Cemetery or Crematory
December 15, 2006 Pine View Cemetery
❑Entombment Address
• ❑Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
4 ❑ Removal and/or Held
▪ and/or Address
Im Hold
0 Date Point of
0 ❑Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
6 ❑ Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01141
Address
136 Main Street, South Glens Falls, New York 12803
~ Name of Funeral Firm Making Disposition or to Whom
ce• Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human remain dip.cribed above as i dicated.
Date Issued 7/4d4 Registrar of Vital Statistics 61/&/tr`7 _ /_� ��►
L� (signature)
District Number ` O7 7 Place South Glens Falls,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 12/15/2006 Place of Disposition pine View Cemetery
W (address)
40 MOHAWK 156-A 1
fl (section) (lot number) (grave number)
Z0 Name of Sexton or Person in Charge of Premises M I C H A E L GENIE R
n (please print)
W
Signature Cv..:4AP. 9iA,.d_4_401h. Title S I 1 P T
(over)
DOH-1555 (02/2004)