Keough, Kristina NEW YORK STATE DEPARTMENT OF HEALTH # 715
Vital Records Section Burial - Transit Permit
— Name First Middle Last Sex
Kristina Jewel Keough Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 22, 2016 56 War or Dates
Place of Death Hospital, Institution or
lit City, Town or Village Queensbury Street-Address 7 G Swan Way
IJI Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined 1-1 Pending
Circumstances Investigation
W Medical Certifier Name Title
Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed &stt„... 49ber Reli$te�Number
City, Town or Village Queensbury (�
❑Burial Date Cemetery or Crematory
September 30, 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
c, ❑Transportation Shipment
f< by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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, Permission is herebygranted to dispose of the human r ins des ibed -b ve as indicated.
Date Issue l j -`` p
1 t (p Registrar of Vital Statistics_ 2t _
(signature)
---- - ,
District Number J Place t D U._,-, Q L L
I certify that the remains of the decedent identified above were disposed of in a rdan a with this permit on:
IDate of Disposition 09/30/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) .� (grave number)
® Name of Sexton or Person in Char e of Premises ar, _ci.tttj
please print)
a Signature e Title Om oat
(over)
DOH-1555 (02/2004)