Forsyth, Joanne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nt
Joanne C. Forsyth Female
Date of Death Age If Veteran of U.S. Armed Forces,
�1, January 22, 2015 86 War or Dates
Place of Death Hospital, Institution or
i City, Town or Village Glens Falls Street Address Glens Falls Hospital
*, Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri"—I Pending
CircumstancesInvestigation
` Medical Certifier Name Title
`r Michael Miles,
. Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 h C l LI 1
®Burial Date Cemetery or Crematory
January 26, 2015 Pine View Cemetery
l ❑Entombment
Address
x U Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
'. Date Point of
, ❑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 as indicated.
Date Issued i l 2 6 ) 15 Registrar of Vital Statistics UN) ,A,k4 s lAJ'ti1\-ce1/4/Q
(signature)
:-13i. District Number 5 6 0i Place 6 (ZANS \,\5 iNi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
g
Date of Disposition 01/26/2015 Place of Disposition Quaker Road Queensbury,NY 12804
t* Ondawa Ext. 32B s) 2
(section) (lot number) (grave number)
Name of Se n or Person in Charge of Premises Connie Goedert
(please print)
'.., Signatu .e Title Cemetery Supervisor
(over)
DOH-1555 (02/2004)