Miller, Loanna NEW YORK STATE DEPARTMENT OF HEALTH t LI
Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
Loanna Ruth Miller Female
W.e Date of Death Age ' If Veteran of U.S. Armed Forces,
,
December 11, 2011 70 War or Dates
Place of Death Hospital, Institution or
- City, Town or Village Ballston Spa Street Address Maplewood Manor
Manner of Death El Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined Ei Pending
ea b Circumstances Investigation
' Medical Certifier Name Title
Leonard Glenman, M.D. Dr.
Address
20 Prospect Street Ballston Spa, NY 12020
Death Certificate Filed District Number Register Number
City, Town or Village Ballston Spa 4520 80
0 Burial Date Cemetery or Crematory
December 13, 2011 Pine View
-❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
EIRemoval and/or Held
'e and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
DateAddress
1 4 Cemetery rY
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
4.1
Permission is hereby granted to dispose of the human remai s described above as indicated.
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�` Date Issued 12-12-2011 Registrar of Vital Statistics �1 L
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tom:; District Number 4520 Place Village of Ballston Spa
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N; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/13/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises I in-)04k., (jry in e%
(please print)
Signature 4.-c � an� L!'e Title rvx-Aurr r
(over)
DOH-1555 (02/2004)