Rourke, Maureen NEW YORK STATE DEPARTMENT OF HEALTH .t TN 3 Zir Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Maureen Ann Rourke Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 24, 2016 61 War or Dates
Place of Death Hospital, Institution or
`` City, Town or Village Northumberland Street Address 83 Leonard Street
Manner of Death J Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
'. Medical Certifier Name Title
Michael Sikirica , Dr.
Address
50 Broad Street Ste 1 Waterford, NY 12188
Death Certificate Filed District Nurneto3 Registe�umber
City, Town or Village Northumberland
❑Burial Date Cemetery or Crematory
April 26, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
I❑ Removal and/or Held
and/or Address
Hold
Date Point of
1111Transportation 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
Address
82 Broadway, Fort Edward NY 12828
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 r ains described above as indicated.
Date Issued oL.) [n i to Registrar of Vital Statistics - ut t f_k/
(signature)
District Number 1-15. Place�C1 wx.-) Q ;{ 0 6.e r 1-- dY /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/26/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) if (lot number) (grave number)
Name of Sexton or Person in Ch ge of Premises a. 5
please pnnt)Signature a 'V Title ( �,e�,
4_
(over)
DOH-1555 (02/2004)