Gerald, Amy NEW YORK STATE DEPARTMENT OF HEALTH
Vital f ecords Section Burial - Transit Permit
Name First Middle Last Sex
A. Amy Lynn Reed Alston Gerald Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 24, 2013 36 War or Dates
-00
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
aw Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined Fl 0 Pending
Circumstances Investigation
9 Medical Certifier Name Title
Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls
5-6oi tiy3
®Burial Date Cemetery or Crematory
October 29, 2013 Pine View Cemetery
❑Entombment Address
`['Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
a. ❑Transportation Shipment
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 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
Permission is hereby granted to dispose of the human remains described above asjndicated.
Date Issued /v f 2-113 Registrar of Vital Statistics L, )cA` g LA.),,,LA-ceL,4-
GG (signature)
District Number S 60 ( Place V(iv\S Fot "�) Ai c/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ii Date of Disposition 10/29/2013 Place of Disposition Quaker Road Queensbury,NY 12804
T -&,. (address)2 O
{ ( ction) (lot number) (grave number)
0` Name of xt n or Person in Charge of Premises v6' �rL �' G6�-6 ic-e
- (please prin
, Signature Title
(over)
DOH-1555 (02/2004)