Adams, Andrea NEW YORK STATE DEPARTMENT OF HEALTH CZ-
Vital Records Section (-" Burial - Transit Permit
Name First Middle Last Sex
Andrea Devlin Adams Female
Livy Date of Death Age If Veteran of U.S. Armed Forces
ate, January 22, 2015 61 War or Dates
Place of Death Hospital, Institution or
-r 3 City, Town or Village South Glens Falls Street Address 15 Saratoga Ave
Manner of Death X❑ Natural Cause n Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
, ;' Circumstances Investigation
Medical Certifier Name Title
Kevin Dooley, Dr.
Address
433 River Street Suite 3000 Troy, NY 12180
# • Death Certificate Filed District Number Register Number
''4 �. City, Town or Village South Glens Falls
-;0 Burial Date Cemetery or Crematory
January 26, 2015 Pine View Crematory
=7,❑Entombment Address
®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
t'• Carrier
4. ❑ Disinterment Date Cemetery Address
' Date Cemetery Address
❑ Reinterment
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 escribed above as indicated.
N' Date Issued 1/4(0///:43--- Registrar of Vital Statistics W/7a.e___. ,dp
4,, b, (signature)
District Number '%. oZ 51 Place /1/ e �20js -Ce-GLS
rt-, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/26/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
d3
(section) (lot number) (grave number)
" Name of Sexton or Person in Char a of Premises 4.41- S
lease pent)
Signature Title ""
(over)
DOH-1555 (02/2004)