Paddock, Louella fi 'NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
--
Name First Middle Last Sex
Louella May Paddock Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 19, 2017 72 War or Dates
Place of Death Hospital, Institution or
City, Tsa #iiiege j010,19q Street Address Saratoga Hospital
Manner of Death
X❑Natural Cause 0 Accident 0 Homicide El Suicide El Undetermined 17 Pending
Investigation
Medical Certifier Name Title Circumstances
0 loliene Boenau,
Address
Saratoga Hospital Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
L City, Town or Village
®Burial Date Cemetery or Crematory
June 11, 2018 Pine View Cemetery
❑Entombment Address
OCremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
4: Date Point of
1 L ❑Transportation Shipment
etX by Common Destination
Carrier
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
tRemains are Shipped, If Other than Above
Address
". Permission is hereby granted to dispose of the human remains described a ove as indicated.
� ��Registrar of Vital Statistics Date Issued(,�..1 t l!�
q c k&I f,
} (signature)
District Number ��-1 Place I CD �� CSC' 4.--
I certify that the remains of the decedent identified above were disposed of in acc• dan - with this permit on:
Date of Disposition 06/11/2018 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
JO Horicon 4D 1
0
I (section) (lot number) (grave number)
Name of Sex on or Person in Charge of Premises Connie Goedert
X 1 (please print)
Wi Signature CULL -r Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)