Geroux, Davina NEW YORK STATE DEPARTMENT OF HEALTH i "'z * Z 2 4
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Davina"DeeDee" J. Geroux Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 27, 2011 35 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
-A Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
x Medical Certifier Name Title
Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
i City, Town or Village 560/ 00/
❑Burial Date Cemetery or Crematory
May 2, 2011 Pine View Crematory
0 Entombment® Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
': Date Point of
❑Transportation Shipment
by Common Destination
qe
Carrier
as
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
°- Name of Funeral Home M. B. Kilmer Funeral Home 01098
Address
82 Broadway, Fort Edward NY 12828
e, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
.: Permission is here y granted to dispose of the human remains de 1,b1 ab as ' ted.
Date Issued may/ Registrar of Vital Statistics �r
T (signature)
District Number 5(oc/ Place ' /577A ky.
g I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/02/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Pe on in Charge f Premises C lt4 p),0 r Sevwt
/ * (please print)
Signature Title CiLas111LA
(over)
DOH-1555 (02/2004)