Regner, Sylvia T 4 131
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sylvia June Regner Female
' Date of Death Age If Veteran of U.S. Armed Forces,
11/04/2017 68 Years War or Dates
IF[ Place of Death Hospital, Institution or
W' City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
w Medical Certifier Name Title
Q Bradley Smith PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 569
❑Burial Date Cemetery or Crematory
11/07/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
~ Hold
O Date Point of
N !MI Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
EI
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
IF- Remains are Shipped, If Other than Above
2 Address
C
IJ
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/07/2017 Registrar of Vital Statistics Men:4 Curtis fectronicaf[ySigned
_
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z DispositionL( ' ) DispositionPint i�
W Date of Place of int .� .ram
2 (address)
W
CO
tY (section) 41 _(lot number (grave number)
g Name of Sexton or Person in Charge of Premises thrs 3t-y-4
Z 1(please print)
W t_.
Signature Title t(REMriL
(over)
DOH-1555 (02/2004)