Miller, Rosemary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rosemary Elizabeth Miller Female
Date of Death 0 6/1 0/2 01 7 Age 81 If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Glens Falls Hospital, Institution or Glens Falls Hospital
W City, Town or Village Street Address
"j Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
W Circumstances Investigation
W Medical Certifier Name Shahid Ahmed Title
n
Address 100 Park St, Glens Falls NY
Death Certificate Filed Glens Falls District Number 5 Register Number
City, Town or Village 3 2-0
❑Burial Date 0 6/1 2/2 01 7 Cemetery or Cremator,
Pine View Crematory
I
['Entombment Address
21 Quaker Rd Queensbury, NY
ID Cremation
Date Place Removed
IS❑Removal and/or Held
...R and/or Address
- Hold
ta
0 Date Point of
0"0 Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to M.B. Kilmer Funeral Home Registration Number
Name of Funeral Home 01 077
Address 123 Main St Argyle, NY 12809
Elp Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
to
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued b/ 12 I (7 Registrar of Vital Statistics WO,L,tyYNCi
(signature) FJ
District Number 5 6 0 ) Place 6 t,,,vj To, 05 /AI y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
Ill Date of Disposition W13(17 Place of Disposition .��t,0ti., er brir"..,
2 (address)
t [
CA
LC (section) A/(lot number) lime (grave number)
�y� Name of Sexton or Person in Charge of Pre - es G Aria
/e'. (ple se print)
Signature
tTitle C1(
(over)
DOH-1555 (02/2004)