Myott, Donna ... - ` 4,773
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Donna Middle Lee Last Sex
Myott Female
i. Date of Death Age If Veteran of U.S. Armed Forces, 1 978-1 981
05/24/2017 65 War or Dates
FW Place of Death Hospital, Institution or
Falls
City, Town or Village Glens Fa Street Address Glens Falls Hospital
Wa Manner of Death❑x Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined El❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Suzanne Rayeski PA
Address 100 Park Street Glens Falls NY 12801
Death Certificate Filed Glens Falls F District Number Register Number ,
City, Town or Village O 6Q1b
0 Burial Date 05/31 /201 7 Cemetery or Crematory Pine View Crematory
❑Entombment Address
EiCremation 21 Quaker RD Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
;;;
1= Hold
O Date Point of
EL
❑Transportation Shipment
Gt 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 01 075
Address 136 Main Street South Glens Falls, NY 12803
ig Name of Funeral Firm Making Disposition or to Whom
1. Remains are Shipped, If Other than Above .
2 Address
CC
LEE
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5 P25 /2G;-) Registrar of Vital Statistics `i�QAm Q,t,rl
(sign,
District Number 5 bo r Place G M$ I II S Ai ; I
! I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ul Date of Disposition /� Place of Disposition �.� a-nG.,
W (add ess)
VI
CC (section) (lot number) (grave number)
Name of Sexton • r in Charge of Premises
.�w 1 i�vi 4�iii1e�'e-
�2 �` � (plea?print)
Signature ,, /�iL t Title �re..r41a.
(over)
DOH-1555 (02/2004)