Doin, T. Irene L.if `Z
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
T. Irene Doin Female
Date of Death Age If Veteran of U.S.Armed Forces,
i. June 4, 2006 93 War or Dates
2 Place of Death Hospital, Institution or
w City,Town,or Village Saratoga Springs Street Address Wesley Health Care Center Inc.
G Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
(0 Medical Certifier Name Title
W
a Address
Death Certificate Filed District Number /. Registerii)nber
City,Town or Village Saratoga Springs
El Burial Date Cemetery or Crematory
June 6, 2006 Pine View Crematory
❑Entombment Address
Z ❑X Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
Hold
16 Date Point of
0 ❑Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
0 ❑Disinterment
❑Reinterment 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
IX
W Address
Permission is per by granted// to dispose of the human remains ri d indicat .
Date Issued tv 6 D t. Registrar of Vital Statistics
(signature)
9 )
District Number'/ Place Saratoga Springs,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 06/06/2006 Place of Disposition Pine View Crematory
2 (address)
41
40
1 (section) lot number)` (grave number)
Name of Sexton or Person in Charge of Premises ( y-(4``Z- G\7 4 d ►J
2 (please print) _
W f1
Signature �JL�✓(� Title G .Z'114 U [_
(over)
DOH-1555 (02/2004)