Mitchell, Theresa NEW YORK STATE DEPARTMENT OF HEALTH 1 1 Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Theresa L. Mitchell Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 22, 2016 78 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Q Manner of Deathifi
Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
it.) Circumstances Investigation
al
Medical Certifier Name Title
William Parker, Dr.
Address
48 East Street Fort Edward, NY 12828
Death Certificate Filed District Number Register Number 1 bq City, Town or Village Glens Falls 5C201
❑Burial Date Cemetery or Crematory
March 23, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
t ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
XRemains are Shipped, If Other than Above
' Address
ffi
ai Permission is hereby granted to dispose of the human remains describ p31/7 ind' .
Date Issued G�3/Z3/�/C Registrar of Vital Statistics
�- (signature)
District Number rj 60/ Place �p/ i'q / JlAs, /(1.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/23/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
fli
f/
IZ (section) (lot number) (grave number)
Name of Sexton or Person in Charge of P emises �� S1xK�
( lease print)
Signature Title
gf
(over)
DOH-1555 (02/2004)