Carpenter, Margaret NEW YORE STATE DEPARTMENT OF HEALTH
VitarRecords Section Burial - Transit Permit
777
Name First Middle Last Sex
Margaret Carpenter Female
Date of Death Age If Veteran of U.S. Armed Forces,
. June 8, 2014 94 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Rm
L.i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
°. Medical Certifier Name Title
i Suzanne Rayeski, Dr.
Address
170 Warren Street Glens Falls, NY 12801
o Death Certificate Filed District Number cl co 1 Reg ist 1-
e er
a Ci Town or Village Glens Falls c
P ®Burial Date Cemetery or Crematory
June 13, 2014 Pine View Cemetery
1,-:*❑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
Carrier
Date CemeteryAddress
❑ Disinterment
Reinterment Date Cemetery Address
j :, 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 ains d cribed ab ve as indi ated.
Date Issued i a . Registrar of Vital Statistics q Z., r ,
(signature)
s District Number ,5ke ( Place
I certify that the remains of the decedent identified above were sposed of in accordance with this permit on:
Date of Disposition 06/13/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Mohawk 10 & 11 2
(section) (lot number) (grave number)
Name of Se n or Person in Charge of Premises Connie L. Goedert
(Please print)
Superintendent
�i
Signature kJ- Title
(over)
DOH-1555 (02/2004)
r