Lague, Jean -ft 1 c
NEW YORK STATE DEPARTMENT OF HEAL-ill 4 I
Vital Records Section Burial - Transit Permit
Name First JeanMiddle L. Last ue Sex Female
9
Date of Death Age If Veteran of U.S. Armed Forces,
01/14/2011 82 years War or Dates
- Place of Death Hospital, Institution or
Z City, Tod4XX�XV NIMX Saratoga Springs Street Address Mary's Haven
ILW Manner of Death�latural Cause ❑Accident ElHomicide ElSuicide ri❑Undetermined ri❑Pending
ti
Circumstances Investigation
Lu Medical Certifier Name Title
0 Darci Gaioth -Grubbs M D
Address
102 Park Street, Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TobGXVAD gX Saratoga Springs 4501 20
❑Burial Date Cemetery or Crematory .
01/18/2011 Pine View Crematory
❑Entombment Address
BCremation Queensbury N Y •
Date Place Removed
2 Z Removal and/or Held
❑and/or
j Address
Hold
1.0
0 Date Point of
1' Trans ortation
�} ❑ P Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01097
Address
136 Main Street, South Glens Falls, New York
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
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fl` Permission is hereby granted to dispcce of the human re:nsi cri d abg.ve as indicated.
Date Issued 01/18/2011 Registrar of Vital Statistics T.
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
lit Date of Disposition I\N[jl MI \Place of Disposition Rat lev., et t j dry+•--
III
(address)
0
CC (section) (lot number) (grave number)
0 Name of Sexton or P r on in Charge of remises ( LuJtr. SPN.,ifr
�� (please print)
Signature k C� A__ Title Cn Pilli l)IC
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(over)
DOH-1555 (02/2004)