Pettkus, Irmgard NEW YORK STATE DEPARTMENT OF HEALTH v �. ,, # 7
Vital Records Section
Burial - Trantit Permit
Name First Middle Last Sex
'roll arj , -k uS Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 20, 2016 80 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Street Address Indian River Health Care Facility
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
,,k4
Medical Certifier ! / C &TA
Title.
Ad rss , 61m W (Wit/
Death Certifica ' d r _, w L� District N er Registe umber
City, Town or illag Q UreP I 1 F= 5
El Burial Date Cemetery or Crematory
Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
O Date Point of
a. ❑Transportation Shipment
411) by Common Destination
O Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Renterment
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
i
a. Permission is he[Zk
eby116
granted to dispose of the human remains d s 'ed - . • l s indicated.
Date Issued 1 Registrar of Vital Statistics !t. P'iWryy
_ ' / ,, (signatuure�J))
District Number 577- Place Vet( 0 — (3ZIteuX J(t(e / t\
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I/ 1I 1/6 Place of Disposition Quaker Road Queensbury,NY 12804 Eta rr�w
(address)
(section) /� (lot number) (grave number)
Name of Sexton or Person in Charge f Premises A ft-0 S le*"
( ease print)
111 Signature It- Title fiXot Fit
T
(over)
DOH-1555 (02/2004)