Hotaling, Brenda NEW YORK STATE DEPARTMENT OF HEALTH 1# ' 1 4
Vital Records Section Burial - Transit Permit
Name First Middle . lilliLast Sex
Brenda Hotaling Female
„„eti Date of Death Age If Veteran cfilU.S. Armed Forces,
September 16, 2016 58 War or Dates
Place of Death , Hospital, Institution or
City, Town or Village Granville Street Address Indian River Rehabilitation
a Manner of Death Fri.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name GkLe • , 4 Title ��g0
6dcolrel p. ls-(W alp ]?D2D
Death Certificate Filed District umber Register Number
City, Town or Village Granville 7a3 5- c3
❑Burial Date Cemetery or Crematory
September 19, 2016 Pine View Crematory
❑Entombment Address
4 ®Cremation Quaker Road Queensbury,NY 12804
4434, Date Place Removed
❑ Removal and/or Held
and/or Address
so.a Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
i 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
1Remains are Shipped, If Other than Above
1 Address
�' Permission is her by ranted to dispose of the human remai esErib: so /.s indicated.
Date Issued `.6 ��ll jo Registrar of Vital Statistics
r / (signature)
District Number 522 5". Place v�G �4( 6 „/ V /dam . -D
certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
_;;; Date of Disposition 09/19/2016 Place of Disposition Quaker Road Queensbury,NY 12804
"* (address)
(section) ///�� (lot number) (grave number)
ao Name of Sexton or Person in Charge of Pre ises L 6f+5 le 5t+vt tit
(please print)
Signature e0t Title titkt
(over)
DOH-1555 (02/2004)