Chmielewski, Alma c
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alma Chmielewski Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 2, 2017 93 War or Dates
Place of Death Hospital, Institution or
Ili City, Town or Village Moreau Street Address 198 Bluebird Road
CI Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Robert Love, Dr.
Address
1 Iron Gate Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Moreau I.;b' ( / y
I1 Burial Date Cemetery or Crematory
March 8, 2017 Pine View Cemetery
0 Entombment Address
❑Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold
0 Date Point of
a. ❑Transportation Shipment
by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
0 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/3 f/- Registrar of Vita! Statistics (, ',— .44 �' .
(signature)
District Number i jc(0 X Place /oCJ✓1 4 r /14 0(e (-._,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
at Date of Disposition 03/08/2017 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
111 9-
re (se 'on) (lot number) (grave number)
pName of Se on or Person in Charge of Premises /,-);See Gbt✓Dt-'k..'
(please print)
lU Signature Titl=.e_t.. ' ' -
(over)
DOH-1555 (02/2004)