Hickok, Harriet NEW YORK STATE DEPARTMENT OF HEALTH c
Vital Records Section Burial - Transit Permit
; Name First Middle Last Sex
Harriet E. Hickok Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 9, 2011 87 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Stanton Nursing & Rehabilitation Center
Manner of Death 0 Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Blood, Dr.
Address
14 Manor Drive Queensbury, NY 12804
Death Certificate Filed District Number Register Number
ti
City, Town or Village 510 0 0)/
f ,❑Burial Date Cemetery or Crematory
March 11, 2011 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
it
Date Place Removed
'.'❑ Removal
and/or and/or Held
Hold Address
Date Point of
❑Transportation Shipment
. by Common Destination
Carrier
A ❑ Date Cemetery Address
Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home
3: Address 01097
AIN
f 136 Main Street, South Glens Falls NY 12803
ly Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
, Address
Permission is hereby granted to dispose of the human remains d cfibe , bove;s in is ted.
Date Issued 3 it- ! Registrar of Vital Statistics 4 ,J
(signature)
District Number s? Place OThv(_L-e__.e_,-NC— -t
Ai I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/11/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numbS (grave number)
Name of Sexton or P on in Charge f Premises � c.s r � tt
2 a (please print)
Signature ce
-s== Title h 60Y�
(over)
DOH-1555 (02/2004)