Shivka, Barbara / # 0 131
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
70 Sex
Name First Middle Last Female
--4 Barbara Delia Shivka
ri
D to of Death Age If Veteran of U.S. Armed Forces,
-° 10/27/2017 88 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death K Natural Cause 0 Accident 0 Homicide Suicide D Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
0 Mathew Varughese DO
Address
44
44 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 554
❑Burial Date Cemetery or Crematory
," 11/06/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
r Date Place Removed
Removal and/or Held
and/or Address
▪ Hold
CO
O Date Point of
rocL Q Transportation Shipment
by Common Destination
14 Carrier
'
(''' Date Cemetery Address
4. �Disinterment
.Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
;' Date Issued 10/30/2017 Registrar of Vital Statistics 9Wert 4 Curtis �ECectronicaaySigned
(signature)
44 District Number 5601 Place Glens Falls, New York
f. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LW Date of Disposition /a /S in Place of Disposition EckL. Cern "tfiw
2 (address)
W.
LL (section) / (Lot number) S (grave number)
4
p Name of Sexton or Person in Charge of Premiss r:, ^se print) ehn�
Signature Ale Title CPla10L
(over)
DOH-1555 (02/2004)