Carruthers, Elizabeth Ann irlIo$
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Elizabeth Ann Carruthers Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/10/2020 92 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
LU Manner of Death Undetermined 1:1Pending
� � Natural Cause �Accident Homicide Suicide
W U Circumstances Investigation
{LI Medical Certifier Name Title
a Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 461
❑Burial Date Cemetery,Crematory or Facility Name
10/13/2020 Pine View Crematory
Entombment Address
gCremation Queensbury Town,New York
ElDonation
Z 1-1 0Removal Date Place Removed
▪ and/or and/or Held
• Hold Address
0
Date Point of
• ❑
d) Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
S Address
CC
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/11/2020 Registrar of Vital Statistics go6ert./?nirew Curtis(EkctronicalySignerl)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit o •
I—
Z Date of Disposition MI /Zo Place of Disposition IILJ
N,. i.,.
address)
W
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of remises (p
Z (p se print/ `�?�,,
UJ Signature Title 6"t""'
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014130
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#