Milne, Jeanette NEW YORK STATE DEPARTMENT OF HEALTH A -)5
Vital Records Section 4 Burial - Transit Permit
Name First Middle Last Sex
Jeanette Milne Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 13, 2011 74 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death® Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Andrew Garner, MD Dr.
Address
2-;c 8 Harrison Ave. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village .5 6C"j 7 5
$' Date Cemeteryor Crematory
0Burial February 16, 2011 ine View Crmatory
',❑Entombment Address
I Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
E Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
•
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
,r Address
123 Main St., Argyle NY 12809
_: 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 descr' V aoys in e
Date Issued ? /' 5 / I ) Registrar of Vital Statistics , /
(signature)
District Number (C�,1 Place G (cn/\S '0, \\5 ) !
-' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I: Date of Disposition 02/16/2011 Place of Disposition Quaker Road Queensbury,NY 12804
_%; (address)
(section) (lot num r) (grave number)
s. Name of Sexton or Person in Charge f Premises L 1r.s} t ehnel%
(please print)
. Si nature / �'� ^�t.m Title a.117A Of.,
(over)
DOH-1555 (02/2004)
i