White, Mary NEW YORK STATE DEPARTMENT OF HEALTH.
Vital Records Section Burial - Transit Permit
Name First Middle - Last Sex
Mary Jane White Female
'& Date of Death Age If Veteran of U.S. Armed Forces,
November 11, 2011 72 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death rcrl
L.Li Natural Cause 0 Accident 0 Homicide 0 Suicide EiUndetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Derck W. Smith,
Address
Death Certificate Filed Distric be Ree�"s er
City, Town or Village 6/'- .4//S/,!Y C)I , - 1
fl 1 Burial Date Cemetery or Crematory
November 15, 2011 West Glens Falls Cemetery
QE--ntombment--. - _
Address —_-__
`:❑Cremation Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
01
�`❑Transportation Shipment
aby Common Destination
Carrier
0 Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 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
; e
Address
Permission is h �C,
rreeby granted to dispose of the human remains described above as indicated.
Date Issued/ i T// lf Registrar of Vital Statistics ( ,,�, ,,��,,c `
(signature)
District Number 561/ Place 6/ 3/1//4 z Cz/ /a i/
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i Date of Disposition 11/15/2011 Place of Disposition Queensbury,NY 12804
(address)
Family Plot Friends Cemetery
,'` (section) (lot number) (grave number)
•
Name of Sexton or Person in rge of Premises Michael Genier
(please print)
Signature g Title Superintpnnt
(over)
DOH-1555 (02/2004)