Daniels, Sally V
t.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sally Ann Daniels Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/09/2018 70 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death IA7 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
g Medical Certifier Name Title
Jean Vanauken PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 528
Ill Burial Date Cemetery or Crematory
11/17/2018 Pine View Cemetery
❑Entombment Address
['Cremation Queensbury Town, New York
�i�i Date Place Removed
?)1 ri❑Removal and/or Held
and/or Address
Hold
Date Point of
S❑Transportation Shipment
a 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-South Glens Falls 01078
Address
j" 136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Q' Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 11/13/2018 Registrar of Vital Statistics Robert A Curtis(ECectronicalTySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
laDate of Disposition) 1 /1 7/201Face of Disposition pine View Cemetery Oueensbury
W" (address)
Se SPnPra #16-1:t 2
(section) (lot number) (grave number)
0 Name of S ton or Person in Charge of Premises Connie Goedert
2 (please print)
1/4(d
SignatureJit 5idLY( Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)