Gillis, Margaret NEW YORK STATE DEPARTMENT OF HEALTH, J�
Vital Records Section t - ` Burial - Transit Permit
Name First Middle Last Sex
Margaret D. Gillis Female
.; Date of Death Age If Veteran of U.S. Armed Forces,
July 23, 2017 71 War or Dates
: Place of Death Hospital, Institution or
City, Town or Village Street Address St. Peters Hospital
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
r,_ Circumstances Investigation
It Medical Certifier Name Title
Address
3 / S r'n / 2 e
:_:$ Death Certificate Filed Distric Numb Register Number
City, Town or Village 1 r9 I L ce 0 u
sal 0 Burial Date / Cemetery or Crematory
/;? ! Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
x Removal and/or Held
and/or Address
Hold
Date Point of
et
4❑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- FE 01079
jvis Address
82 Broadway, Fort Edward NY 12828
At Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h7/ 7/
ebyanted to dispose of the human remains describ d abo e as indicated.
611.9-
Date Issued �� g
Re istrar of Vital Statistics bo,ptilig... 1p,�
(sig ature)
District Number /,d/ Place 4407
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Pp�Q _RA/ £f - o
Date of Disposition y 2!u 17 Place of Disposition Quaker Road Q�ueensbury,NY 12804�
(address)
(section) (lot number) (grave number)
Name of Sexton or P rson i Charge of Premises �pvt r ,,,,,- .^"' E41.--
(please tint)
Signature Title --/-e� 41.
(over)
DOH-1555 (02/2004)