Meyers, Terri NEW YORK STATE DEPARTMENT OF HEALTH , 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Terri Lynn Myers F
Date of Death Age If Veteran of U.S. Armed Forces,
Aug . 13 , 2006 39 War or Dates
• Place of Death Ci t y of Glens Falls Hospital, Institution or Glens Falls Hospital
City, Town or Village Street Address
0 Manner of Death Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending
kt Circumstances Investigation
tu Medical Certifier Name Title
O Timothy E. Murphy Coroner
Address
52 Havilanc Ave. Glens Falls , NY 12801
Death Certificate FiledC i t y of Cl e n s Falls District Number LL Regist Numbr
City, Town or Village 5 V 0 1
Fii❑Burial Date Cemetery o�Cremato
Aug . 17 , 2006 Pine V era Creiatory
0 Entombment Address
[Cremation nuoensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or
� Address
I/
Hold
O Date Point of
fati 0 Transportation Shipment
Q by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home O1141
Address
136 Main St . South Glens Falls , NY 12803
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
,'; Address
al
U/
` Permission is hereby granted to dispose of the human remains describ o
e a dica
Date Issued ¶ //1-4 J( 6 Registrar of Vital Statistics
(signature)
District Number S 'O 1 Place 6 (C/Ar•S -W t L S / ti Y
k
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
111 Date of Disposition V/ti AL Place of Disposition Anevi r va CI.cw,,Nt-or,J n.
2 (address)
tli
W.
(section) (lot number) (grave number)
• Name of Sexton or Person jn Charge of Premises C h "' J S o n r.,1 01
*� (please print)
Signature Title Cfr"t f or
(over)
DOH-1555 (02/2004)