Cooper, Patricia NEW YORK STATE DEPARTMENT OF HEALTH y7v
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia Ann Cooper Female
Date of Death Age If Veteran of U.S.Armed Forces,
I. October 23, 2006 73 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death Eci Natural Cause ❑ Accident ❑Homicide n Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
Medical Certifier Name Title
W Dr Frances Bollinger Dr
Q Address
Moreau Family Health Center, Fort Edward, NY 12803
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls S bo 1 5 --2-1-1
.
❑Burial Date Cemetery or Crematory
October 24, 2006 Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road Queensbury, NY 12804
2 Date Place Removed
4 ❑Removal and/or Held
and/or Address
I" Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
❑Disinterment
El Renterment 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
2 Remains are Shipped, If Other than Above
ft
W Address
O.
Permission is hereby granted to dispose of the human remains describe above as i icat .
f
Date Issued 02H [0,6 Registrar of Vital Statistics E !
ve
(signature)
District Number 5b0( Place Glens Falls,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 10/24/2006 Place of Disposition Pine View Crematory
3 (address)
W
41
CC (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises CI,c,. SoII�.,-
Z ��� t
(please print)
Signature +vr Title Cmfiastci
(over)
DOH-1555 (02/2004)