Failova, Angela -. 'N # 11 g
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Angela Fallova Female
Date of Death Age If Veteran of U.S. Armed Forces,
' 12/04/2018 75 Years War or Dates
po., Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death J Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
tiCircumstances Investigation
w Medical Certifier Name Title
Q Stephen Perazzelli MD
Address
100 Park St,Glens Falls,New York 12801
IA Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 570
El Burial Date Cemetery or Crematory
12/06/2018 Pine View Crematory
Entombment
Address
g'`®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
— and/or Address
t Hold
Date Point of
to Li Transportation Shipment
by Common Destination
Carrier
,, Date Cemetery Address
Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
h..
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
';,, 136 Main St,S Glens Falls,New York 12803
y Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
111*
Permission is hereby granted to dispose of the human remains described above as indicated.
P.
Date Issued 12/05/2018 Registrar of Vital Statistics Wp6ert JA Curtis(ETctronicaltySigned)
(signature)
District Number 5601 Place Glens Falls, New York
Y":
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
V Date of Disposition IL I I• iI g Place of Disposition it 4 c r..�.
(address)
(section) of number) (grave number)
Name of Sexton or Person in Charge of Premises [his • "— ,) e "'
S // (p/eaie print)
Signature Title lC34
(over)
DOH-1555 (02/2004)