Baltzersen, Edith NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section .K-:r . Burial - Transit Permit
Name First Middle Last Sex
4 Edith Baltzersen Female
-` Date of Death Age If Veteran of U.S. Armed Forces,
N. November 28, 2018 99 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 15 Pine Valley Drive
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson,
Address
161 Carey Road Queensbury, NY 12804
'=• Death Certificate Filed DistrictNumber Register Number
City, Town or Village Moreau ` ,Lj
❑Burial Date Cemetery or Crematory
November 29, 2018 Pine View Crematory
• 0 Entombment Address
I Cremation Quaker Road Queensbury,NY 12804
u Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
_ ' ❑Transportation Shipment
by Common Destination
Carrier
❑ Date Cemetery Address
Disinterment
-
❑ Reinterment Date Cemetery Address
;V Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
;' Address
. 136 Main Street, South Glens Falls NY 12803
4. N• ame of Funeral Firm Making Disposition or to Whom
' R• emains are Shipped, If Other than Above
Address
S Permission is hereby granted to dispose of the human re descri • ab a indicated.
• Date Issued //f j /j/3 Registrar of Vital Statistics /tfliA,A-( /
(si ature)
District Number Place /2 1( Q u, /1 I/, /0�',)�
' `K I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
'? Date of Disposition 11/29/2018 Place of Disposition Quaker Road Queensbury,NY 12804 p:oR, V.f i cry Y
(address)
e (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Jcui' J' 5?).i 1 ft'
(please print)
Signature Title i^e, (13°r
(over)
DOH-1555 (02/2004)