Breton, Sylvia NEW YORK STATE DEPARTMENT OF HEALTH " 01
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
0 Sylvia Jean Breton Female
wi
Date of Death Age If Veteran of U.S. Armed Forces,
December 22, 2011 69 War or Dates
4 Place of Death Hospital, Institution or
4 City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Christopher D. Hoy, M.D. Dr.
Address
-;' 102 Park St. Glens Falls, NY 12801
;, Death Certificate Filed District Number / O) Register Number
PW C�City, Town or Village
0 Burial Date Cemetery or Crematory
x.- -. December 23, 2011 Pine View
I 1-1
❑Entombment
Address
I Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
- and/or Hold Address
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
IllReinterment Date Cemetery Address
Registration Number i
4-k; Permit Issued to Re 9�
7,..40 Name of Funeral Home M. B. Kilmer Funeral Home:ow 01079
tp Address
24' 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 remains descri d ab ve in
'� / Registrar of Vital Statistics G
Date Issued �� �'/
(signature)
District Number jam/ Place -4 / 7/ Nx
m I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/23/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /`� (lot number) (grave number)
" Name of Sexton or Pe on in Charg of Premises (` r,st r Sege#
(please print)
- Signature Title Ali MFDK
(over)
DOH-1555 (02/2004)