Boyer, Leah NEW YORK STATE DEPARTMENT OF HEALTH # (1 b
Vital Records Section r 11,, Burial - Transit Permit
i E Name First Middle Last Sex
Leah N. Boyer Female
Date of Death Age If Veteran of U.S. Armed Forces,
• September 29, 2011 77 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Stanton Nursing & Rehabilitation Center
Manner of Death IL.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
•: Medical Certifier Name Title
Roslyn Socolof, M.D. Dr.
•
t• Address
4 100 Broad Street Glens Falls, NY 12801
Death Certificate Filed Dis&ict Number Register Number
City, Town or Village I 1 01
❑Burial Date Cemetery or Crematory
October 3, 2011 Pine View
❑Entombment Address
e ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
11
Date Cemetery Address
❑ Renterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
f
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Y,4
Permission is: hereby granted to dispose of the human re ins described hove as indicated.
= Date Issued) )21�11 Registrar of Vital Statistics �` Y`�`� Q .Cam'->n-��
t (signature)
,, District Number t c ) Place ) v„---N ` ? L _eA )
,I,„,
it I certify that the remains of the decedent identified above were disposed of in ac . da ce with this permit on:
- Date of Disposition 10/03/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
2e5 (lot number) (grave number)
` ' Name of Sexton or Person in Charge of Premises I inio by (i\c.)✓t eIte
_� (please p--riin^nt))^ ,,
Signature Title C('em tiSt -
(over)
DOH-1555 (02/2004)