Russell, Jean NEW YORK STATE DEPARTMENT OF HEALTH ,' # til
Vital Records Section Burial - Transit Permit
s , Name First aMiddle Last Sex
tV Jean Ruth Russell Female
ft Date of Death Age If Veteran of U.S. Armed Forces,
x : October 11, 2011 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 9 Argyle Street
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name
Title
Robert Sponzo, Dr.
Address
. ' 102 Park St. Glens Falls, NY 12801
Death Certificate Filed District umber Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
October 14, 2011 Pine View Cemetery
j
El Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
w❑ Removal Date Place Removed
and/or and/or Held
Hold Address
Date Point of
,-,❑Transportation Shipment
by Common Destination
-' Carrier
❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
f
11-,r Permit Issued to Registration Number
'' Name of Funeral Home M. B. Kilmer Funeral Home 01079
r.
47 Address
, 82 Broadway, Fort Edward NY 12828
tit Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he by anted to dispose of the human r ns described a ove s indicated.
LA Date Issued/('] 4 _ X/ Registrar of Vital Statistics J
.�— (signature)
Ti
District Number5-7.i..1 Place
>` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
` Date of Disposition 10/14/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or P son in Charg of Premises 4r:sie e e r t
. (pl ase print)
'; Signature
... 9 Title CtLe m+ tOf�.
(over)
DOH-1555 (02/2004)