Irish, Louella •
cgs
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Louella W.Irish Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/20/2017 94 YearS War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death I Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
a Medical Certifier Name Title
William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
4 City, Town or Village Glens Falls 5601 598
• ❑Burial Date Cemetery or Crematory
y^ Y 11/21/2017 Pine View Crematory
Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
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-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
8a
Address
r
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/21/2017 Registrar of Vital Statistics Ro6ert/3Curtis ElectronicallySigne6
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance1 with this permit on:
Date of Disposition III 21 In Place of Disposition i Inc 1it•✓ L/�'y^ o c
(address)
(section) 4lot number) (grave number)
• Name of Sexton or Person in Charge of Premises l(r�. �a�►�lbt
(plea e print)
• Signature Title Mt 1Q
(over)
DOH-1555 (02/2004)