Callan, Valeria ff—
NEW YORK STATE DEPARTMENT OF HEALTH if q
Vital Records Section 0 ._, Burial - Transit Permit
Name First Middle Last Sex
Valeria "Val" Callan Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 9, 2016 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Marvin Davidowitz, Dr.
Address
:fi Glens Falls Hopital Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
o )
City, Town or Village Glens Falls 5 6 i o
❑Burial Date Cemetery or Crematory
December 14, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
t'`❑ Removal and/or Held
v and/or
Hold Address
et Date Point of
a. ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
v Name of Funeral Firm Making Disposition or to Whom
Iyy: Remains are Shipped, If Other than Above
Address
w"
sue+ Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 Z( i 3 j�c 1 Registrar of Vital Statistics w J . .,A...)(signat'AJure
District Number 5 (:Gr Place c S V'EI.\,k c ,Ov y
I certify that the remains/�oapf the decedent identified above were disposed of in accordance with thistr� permit on:
Date of Disposition 12/ /2016 Place of Disposition Quaker Road Queensbury,NY 12804 1"/ ;,/jie)e—/ern47;j y
(address) //
at (section) \ mb(lot nu r) (grave number)
2; Name of Sexton o � C rge of Premises L /t ti-i4 ( ,v aG�.R
2 (please print)
tll.' Signature Title C'fe-Pri -71-'/-
(over)
DOH-1555 (02/2004)