Ward, Carol NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Perm":g=
Name First Middle Last Sex
11 Carol Ann Ward Female
NI Dante oFDeath Age If Veteran of U.S. Armed Forces,
5/2 3/2 01 8 7 6 War or Dates No
144 Place of Death Hospital, Institution or
City, Town or Villa lens Falls
9 Street AddressGlens Falls Hospital
a Manner of Death IzilNatural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
lig Medical Certifier Name Title
P. PU) ) Pinft0 M 0
Address
/D Z Re,V 5V. N'r Filli 6- Pt ftg0
y Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls S(0O 1 ZS�
Burial Date Cemetery pr Cremato
5/25/2018 Pine `7iew Creatory
['Entombment Address/
$,Cremation Queensbury, NY
Date Place Removed
Removal and/or Held
'� and/or Address
H Hold
U,
Date Point of
t:` Transportation Shipment
C by Common Destination
iiiiiiii Carrier
Disinterment Date Cemetery Address
❑Reinterment Date " Cemetery Address
Eil Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01 077
Address
iiiM 123 Main St. Argyle, NY 12809
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
w
Permission is hereby granted to dispose of the human remains descr' ed above s ii►c ted.
Date Issued 5/2 5/2 01 8 Registrar of Vital Statistics <<7
(signature)
District Number 5601 Place Glens Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tii• Date of Dispositionsc2q-(v Place of Disposition di'd(Itth'eAkt
Ili
(address)
LC (section) (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises SZJ h[4/ LT4,IIVSS,
*2 (please print)
Signature.. "� Title er,, f ct' 4_
::::,„::::
(over)
DOH-1555 (02/2004)