DeSimone, Sylvia Lt
NEW YORK STATE DEPARTMENT OF HEALTH It ?.
Vital Records Section Burial - Transit Permit
El Name First Middle Last Sex
Sylvia E. DeSimone F
Date of Death Age If Veteran of U.S. Armed Forces,
5/01 /2 01 1 8 3 War or Dates
F- Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Pleasant Valley Infirmary
JAI0 Manner of Death®Natural Cause 0 Accident ElHomicide ❑Suicide Undetermined ri❑Pending
IW Circumstances Investigation
CA
tij Medical Certifier Name Title
0 dd Edit Masaba Dr.
1134 State Rotee9, Greenwich, New York 12834
iME Death Certificate Filed Argyle District Number 5.7 Register Number
ini City, Town or Village
❑Burial Date Cemetery or Crematory
5/04/2011 PineView Crematory
❑Entombment Address
iliii®Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
�
and/Holdor Address
=
ODate Point of
Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registrc Gaon Number
Name of Funeral Home M. 13. Kilmer Funeral Home 0T098
Address
82 Broadway, Fort Edward, NY 12828
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
1r
tia
Permission is hereby granted to dispose of the human re i s described abo e indicated.
ei Date Issued O 41.20 (f Registrar of Vital Statistics t
(signature)
Wii District Number 5`1 S p Place 7jn C-( Prlyc__
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k �
Iti Date of Disposition S't'I Place of Disposition 19,420,X4 / ;vre{dV'I sh..
(address)
UI
to
cc (section) r (lot numb (grave number)
CI (.Name of Sexton or Arson in Char 'e of Premises . � it --. 041.
f (please print)
) Signature [ _Jt L Title C't7 11115r1W
(over)
DOH-1555 (02/2004)