Mirman, Janet • # SOS
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle �L�ast Sex
JanetSusan Mirman remale
Date of Death Age If Veteran of U.S. Armed Forces,
06/18/2018 72 years War or Dates
Place of Death Hospital, Institution or
Z City, Q AVOWGlens Falls Street Address Glens Falls Hospital
0 Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide n Undetermined r7 Pending
Ua Circumstances Investigation
W Medical Certifier Name Title
Paul Fillon M D
Address
2 Irongate Plaza Glens Falls, Ny 12801
<; Death Certificate Filed District Number Register Number
City, 4)( a Glens Falls 5601 307
<<DBurial Date Cemetery or Crematory
06/20/2018 Pine View Cematory
[]Entombment Address
;,"❑Cremation Queensbury, Ny
Date Place Removed
2❑Removal and/or Held
and/or Address
5 Hold
Date Point of
Transportation Shipment
Q by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to ReQisOt78 ion Number
Name of Funeral Home M. B. Kilmer Funeral Home 0'
Address
136 Main Street South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
114 Remains are Shipped, If Other than Above
Address
11,1
'` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/20/2018 Registrar of Vital Statistics U)� ,- ,tip
(s nature)
District Number5601 Place Glens Falls 61(./
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �� ,�
It Date of Disposition t,/t t )5$ Place of Disposition 6J—I G r or, _
(address)
U
t
IX (section) lot number) c (grave number)
:p Name of Sexton or Person in Charge of Premises 4r,�1 S 0..�y -
," g (please print)
i Signature Title f rtb1-
(over)
DOH-1555 (02/2004)
I