Battease, Adrienne 11
NEW YORK STATE DEPARTMENT OF HEALTH _ i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Adrienne Margaret Battease Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 17, 2017 79 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death FriNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
U Circumstances Investigation
W Medical Certifier Name Title
Ci Shamid Ahmed, Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number C'. Register Number
City, Town or Village Glens Falls / 6
r
❑Burial Date Cemetery or Crematory
January 18, 2017 Pine View Crematory
❑Entombment Address
]Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
p and/or Address
F Hold
Date Point of
❑Transportation Shipment
f/a by Common Destination
O Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
MAddress
W
0' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 ) I rS I' -c I Registrar of Vital Statistics c p- k1 L, c
(signature)
District Number 560, Place VSn
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 01/18/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
a (section) '/ (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises ,Sl°4e
ti
(p ase print)
IJJ Signature LPL Title CR /4t ,t—
(over)
DOH-1555 (02/2004)