Corbett, Donna NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donna Rae Corbett Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/23/2018 58 Years War or Dates
AZPlace of Death Hospital, Institution or
a City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death izirul Natural Cause ['Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
la Circumstances Investigation
ui Medical Certifier Name Title
Philip Gara MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
; City, Town or Village Fort Edward 5755 30
❑Burial Date Cemetery or Crematory
06/26/2018 Pine View Crematory
['Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
t 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
Remains are Shipped, If Other than Above
Address
CC
ILI
Permission is hereby°ranted to dispose of the human remains described above as indicated.
Date Issued 06/26/2018 Registrar of Vital Statistics Aimee Ma/ioney(E(ectronica11ySigned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
liki
Date of Disposition (i Ji9 fig Place of Disposition eft , �'n�.for„ .
(address)
(section) /jot number) ` (grave number)
pName of Sexton or Person in Charge of Premises L l 11L Je��lt
�Z (pie se print)
-41 4
Signature l i[ Title Civithir t
(over)
DOH-1555 (02/2004)