Roberts, Joan -14
NEW YORK STATE DEPARTMENT OF HEALTH * • (ilia
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joan Daisy Roberts Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 15, 2012 80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death rcnu Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed District Number Regis�te�Number
City, Town or Village Fort Edward ,3 755 7lS
1
❑Burial Date Cemetery or Crematory
August 17, 2012 Pine View Crematory
ID Entombment Address
was
®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
Ill Disinterment
Date Cemetery Address
❑ Renterment Date Cemetery Address
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
ter. Remains are Shipped, If Other than Above
Address
Permission is h reby ranted to dispose of the human ains describe ove a 'ndicated.
9
Date Issue
Registrar of Vital Statisti
,�--� (signature)
District Numbe�7s� Place /� 1—Zi '
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/17/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) A (lot number) S (grave number)
Name of Sexton or Person in Charg f Premises A n;tot/r (1)
(please print)
SignaturedilL Title CR'm"Aitt
(over)
DOH-1555 (02/2004)