McEachron, Doris NEW YORK STATE DEPARTMENT OF HEALTH # J Z
Vital Records Section i. r Burial - Transit Pe
rmit
emit
, Name First Middle Last Sex
Doris I McEachron Female
- Date of Death Age If Veteran of U.S. Armed Forces,
October 20, 2011 93 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville Street Address Indian River Health Care Facility
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
4 Circumstances Investigation
Medical Certifier Name Title
' A Jennifer Hayes,
Address
17 Madison Street Granville, NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village
J❑Burial Date Cemetery or Crematory
October 24, 2011 Pine View
;'❑Entombment
��,3 Address
uv 1®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
ElDisinterment Date Cemetery Address
IIIReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
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 hereb granted to dispose of the human remains Via
. ,o 'cated.
Date Issued 101Z.1 Registrar of Vital Statistics V
II (signature)
District Number c12 S Place &arm l I e.
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
x€ Date of Disposition 10/24/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
! (section) /1 lot numbe (grave number)
Name of Sexton or Per n in Charge of remises L 4 - r 104t
f�� (please print)
.: Signature h Title CRfl'1 (0A-
(over)
DOH-1555 (02/2004)