Breyo, Louise NEW YORK STATE DEPARTMENT OF HEALTH ' T2
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Louise Breyo Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 19, 2017 92 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide n Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
O Frances Bollinger, Dr.
Address
161 Carey Rd. Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls S 6 0/ 5 L(
❑Burial Date Cemetery or Crematory
January 24, 2017 Pine View Crematory
❑Entombment Address
,1Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
Hold
Date Point of
▪ ❑Transportation Shipment
(I) by Common Destination
8 Carrier
Date Cemetery Address
El Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
W
W Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ! 1 2 W / /7 Registrar of Vital Statistics J Ca..w . , W
(signature
District Number 5 :7 C ( Place C (QA" S rc.k\\S1 l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 01/24/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
[e (section) / (lot number) - (grave number)
pName of Sexton or Person in Charge of Premises ��'����
( lease print)�n�+
W Signature Gl �"� Title ��Et�"��'
(over)
DOH-1555 (02/2004)