Palladino, Roxanne - if r) J
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
°a Rnxanne Palladino Female
`. ' Date of Death Age If Veteran of U.S. Armed Forces,
1 2/8/1 4 63. War or Dates No
Place of Death Hospital, Institution or 4573 State Rt. 40 Argyle
City, Town or Village Argyle Street Address Washington Center
im Manner of Death®Natural Cause El Accident El Homicide 0 Suicide El Undetermined 7 Pending
Circumstances Investigation
ei
at Medical Certifier Name Title
'Edit Ma_s MD
Address
Death Certificate Filed District Number Register Number
>> City, Town or Village Argyle _ `S 75 -S�
['Burial Date Cemetery or Crematory
:' ❑Entombment 1 2/9/1 4 Pine View Crematory
Address
'>:;®Cremation Q„eenchnry, NY
Date Place Removed
Removal and/or Held
and/or Address
Hold
X
Date Point of
ikQ Transportation Shipment
a by Common Destination
M: Carrier
> Q Disinterment Date Cemetery Address
: Q Reinterment Date Cemetery Address
'` Permit Issued to Registration Number
Name of Funeral Home M.B.Kilmer Funeral Home 01 078
Address
82 Broadway, Fort Edward, NY 12828
i" Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i
l
Permission is hereby granted to dispose of the human remains described above as indicated.
'< Date Issued J 2) gS) 614 Registrar of Vital Statistics e 0 Q YY)c./t,,A,,,o
(signature)
Vii
District Number 5-7 S� Place (e„ _y li i NJ -
4iiii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ti
ILI Date of Disposition ti!toIII Place of Disposition ,rL ,,t,,.i �, j`�,
(address)
ll
MI
(section) j (lot number) (grave number)
Ca
Name of Sexton or Person in Charge of Pr mises `).t . ,cs
j (please print)
Signature �� — Title erlif.1141104-
(over)
DOH-1555 (02/2004) •