Condon, Lois NEW YORK STATE DEPARTMENT OF HEALTH It."Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lois Jane Condon Female
Date of Death Age If Veteran of U.S.Armed Forces,
). April 25, 2006 83 War or Dates
Z Place of Death Hospital, Institution or
W City,Town, or Village Granville Street Address Indian River Health Care Facility
0 Manner of Death M Natural Cause 0 Accident 0 Homicide ElSuicide El Undetermined 0 Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Max Crossman M.D. Dr.
Q Address
79 North Street, Granville, NY 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville 1-3
❑Burial Date Cemetery or Crematory
April 26, 2006 Pine View Crematory
❑Entombment Address
2 Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
and/or Address
I' Hold
Date Point of
0 0 Transportation Shipment
a by Common Destination
i Carrier
Date Cemetery Address
Q �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
H Name of Funeral Firm Making Disposition or to Whom
re re Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remain ••; ` - • • e .s indicated.
Date Issued i la&)OQ Registrar of Vital Statistics ( i ♦ H 11.
(signature)
District Number 5—Pb Place Granville,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 04/26/2006 Place of Disposition Pine View Crematory
2 (address)
W
0
g (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises 6 P tz Ce,1t$. /V
W (please print)
Signature a�- k t�Jti. Title C.R.l/1/7 j CZ
(over)
DOH-1555 (02/2004)