Williams, Mary rr
P-/br
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Lorraine Williams Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/15/2018 96 Years War or Dates
- Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Lair7INatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
O Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 87
El Burial Date Cemetery or Crematory
02/19/2018 Pine View Crematory
❑Entombment Address
IN Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
2 and/or Address
tHold
Date Point of
❑Transportation Shipment
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
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/16/2018 Registrar of Vital Statistics Rg6ertJ7 Curtis(ECectronica1TySigned)
(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:
Z/Zllip DispositionF V ( 4
Date of Disposition Place of ,N .� t+►•ti a
(address)
ILI
(section) (lot number (grave number)
p Name of Sexton or Person in Charge of Premises
please print)
• Signature 6 / Title ff0044
(over)
DOH-1555(02/2004)