Hover, June NEW YORK STATE DEPARTMENT OF HEALTH " ' #16g
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
June Hover Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 5, 2017 78 War or Dates
tPlace of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
WW Medical Certifier Name Title
Farhana Kamal, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number ` Re jst ber
City, Town or Village Glens Falls �`a) 1
❑Burial Date Cemetery or Crematory
June 6, 2017 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date ' Place Removed
ri Removal and/or Held
and/or Address
Hold
0 Date Point of
0i. ❑Transportation Shipment
by Common Destination
Q Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2, Address
W
11' Permission is hereby ranted to dispose of the human ..mains A. -scrib • above a- Indic ted.
Date Issued egistrar of Vital Statistics A% i A APB
(signature)
District Number / Place 2A ,d
,
— I certify that the remains of the decedent identified above were disposed Olin acco ance with this permit on:
w Date of Disposition 06/06/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
CO
te (section) lot number) (grave number)
p` Name of Sexton or Person in Charge of remises G ra y Jennitt
Z (ple se print)
W Signature R Title L 0491-
(over)
DOH-1555 (02/2004)