Kilmartin, Angela NEW YORK STATE DEPARTMENT OF HEALTH , _ , .11 Lio CI
Vital Records Section Burial - Transit Permit
Vi Name First Middle Last Sex
Angela Jean Kilmartin Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/16/2011 • I 50 years War or Dates
1- Place of Death Hospital, Institution or
W
City, To 40: X Glens Falls Street Address C;lanc Falls Hospital
• Manner Deat \;Iatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ILI Circumstances Investigation
0
Medical Certifier Name Title
II
AddAg�ni M_D
res102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, To
v► tiJiftiteXX C,IPns Falls 5601 356
❑Burial Date Cemetery or Crematory
DEntombment AddressO6/17/2011 Pine View Cemetery
Agremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
0and/or❑ Address
N Hold
O Date Point of
N ❑Transportation Shipment
C by Common Destination .
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to • Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
2 Address
1!4J
fl` Permission is hereby granted to dispose of the human remains described bove indi .
Date Issued 08/17/2011 Registrar of Vital Statistics ��
(signature)
iM District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
til
Date of Disposition (-1�(-1 l Place of Disposition g u u� Crc'-4o f'+ .
a (address)
Lu
CO
Cr (section) /J (lot numbe (grave number)
Name of Sexton or Per n in Charge Premises r [y
(please print)
• Signature if" — Title C<zt pi 4CoL
(over)
DOH-1555 (02/2004)