Cross, Rita NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FirstRita Middle May La Sex ross Female
Date of Death Age If Veteran of U,S. Armed Forces,
01/11/2011 77 years War or Dates
}- Place of Death Hospital, Institution or
W City, To+)Gi :9XVIM X Saratoga Springs Street Address Saratoga Hospital
Manner of DeathNatural Cause 1=IAccident 0 Homicide El Suicide ElUndetermined ri Pending
ILI Circumstances Investigation
W. Medical Certifier Name Title
Edward M. Liebers Md
Add-
es
a •are Lane, Suite 300, Saratoga Springs, Ny
z Death Certificate Filed District Number Register Number
City, ToMPVVVWX Saratoga Springs 4501 11
❑Burial Date Cemetery or Crematory
01/13/2011 Pine View Crematory
.<ii []Entombment Address
>`: [ Cremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
9.❑and/or
Address
Hold
61
0 Date Point of
k;0 Transportation Shipment
try
0 by Common Destination •
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.b. Kilmer Funeral Home 01096
Address
123 Main Street, Argyle, N Y
•
31 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
cr
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/13/2011 Registrar of Vital Statistics �� �J__ 1 lt,,,,,JL____
�� (signature)
District Number 4501 Place Saratoga Springs
::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z (r,�� � f ti
I<tt Date of Disposition St,, Hi 7a1�Place of Disposition "1 1ntV,1w Creiv,,mdr,i„`
W (address)
0
fr (section) (lot number' (grave number)
QName of Sexton or Person in Char e of Premises rsi_�.pl✓,.- - et.trtt
/ i(please print)
Signature Title iii CIL<< K 4 P nt
(over)
DOH-1555 (02/2004)