Chadwick, Pearl ti Is
NEW YORK STATE DEPARTMENT OF HEALTH lb
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Pearl M. Chadwick Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 17, 2011 95 War or Dates
Place of Death Hospital, Institution or
r. City, Town or Village Glens Falls Street Address Glens Falls Hospital
r: Manner of Death 0 Natural Cause 0 Accident:0 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Devon Bock,
t
Dr.
Address
17 Baywood Dr. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 60 5
❑Burial Date Cemetery or Crematory
September 20, 2011 Pine View
0 Entombment Address
®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
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
1 Name of Funeral Home M. B. Kilmer Funeral Home 01079
.r, Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,. Address
i Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ci' i 2tY i i Registrar of Vital Statistics w W1/4`1 _a- �"� --A- 1
`` ,.'{�"," (signature)
District Number 5 6o I Place u l9Jvfs 7'\\s 1�
'= I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/20/2011 Place of Disposition Quaker Road Queensbury,NY 12804
` (address)
(section) (lot number) (grave number)
Name of Sexton or Per n in Charg of Premises 1'lri Ser�tft
°- + (p ase print)
Signature QFr,
9 Title C o
(over)
DOH-1555 (02/2004)