Adams, Leona NEW YORK STATE DEPARTMENTOF HEALTH f
Vital Records Section Burial - Transit Permit
1,1 Name First Middle Last Sex
Leona May Adams Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/20/2017 76 Years War or Dates
Place of Death Hospital, Institution or
fu City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 5Lej Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village GleeFalls 5601 542
['Burial Date Cemetery or Crematory
, 10/24/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New'
Date Place Removed
ri fl Removal _ and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
,2' 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-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
,71 Date Issued 10/23/2017 Registrar of Vital Statistics Robert A Curtis Etectronica1TySigned
(signature)
District Number 5601 Place Glens Falls, New York
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Y Date of Disposition /0/Zb i ll Place of Disposition f rs� (r cjv r'
(address)
(section) / {lot number) (grave number)
411,
Name of Sexton or Person in Charge of Premises 10 "'A
(ple se print)
Signature Title E
(over)
DOH-1555(02/2004)