Hance, Muriel NEW YORK STATE DEPARTMENT OF HEALTH ft /1 )
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Muriel Haas Hance Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 12, 2016 91 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 75 Seminary Street
Manner of Death
Natural Cause ❑ Accident El Homicide ❑ Suicide ❑ Undetermined ❑ Pending
C.) Circumstances Investigation
Medical Certifier Name Title
Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
Death Certificate Filed District Numbe �� Register*tuber
City, Town or Village Fort Edward 4 ,0
❑Burial Date Cemetery or Crematory
March 14, 2016 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
2 ❑ Removal and/or Held
and/or Address
Hold
O Date Point of
• ❑Transportation Shipment
by Common Destination
el Carrier
❑ Disinterment Date Cemetery Address
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
, Permission is reb granted to dispose of the hums escribbee ib e dicated.
Date Issue Registrar of Vital Statistics Y
�� , ignature)
District Number Place UleVt- / d-----
II certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/14/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) y(lot number) (grave number)
Name of Sexton or Person in Chare of Premises SUM+
444Atilg
( lease print)
Signature a Title ( i(0
T
(over)
DOH-1555 (02/2004)