Hervieux, Linda NEW YORK STATE DEPARTMENT OF HEALTFti - . b #G 6 6--
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Linda S. Hervieux , Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 13, 2016 75 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
a- Circumstances Investigation
-, Medical Certifier Name Title
Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
Death Certificate Filed District Number Register umber
City, Town or Village Fort Edward 5 5- (iLP
El Burial Date Cemetery or Crematory
September 16, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
I; Removal and/or Held
and/or Address
Hold
aa
O Date Point of
1 : El Transportation Shipment
by Common Destination
O Carrier
riDisinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
• 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
Permission is hereby granted to dispose of the human ins described above a indicated.
Date Issued9—/�—// c:Registrar of Vital Statistic C
District Number�75$— Place
/ 41 �f �s (n tc✓
i
2 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
. Date of Disposition 09/16/2016
p Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Ill
(section) /� (lot number) r (grave number)
Name of Sexton or Person in Charge f Premises /[PSPAwE
(please print)
I" Signature et �/� CR2
Title l
(over)
DOH-1555 (02/2004)