Beadleston, Mary NEW YORK STATE DEPARTMENT OF HEALTH'
# 52 7
Vital Records Section .,.- ,- , ., Burial - Transit Permit
Name First , Middle Last I Sex
Mary Sin Beadleston I Female
Date of Death i Age If Veteran of U.S.Armed Forces,
8/13/2016 58 or Dates -
Place of Death Hospital. Institution or
ii City, Town or Village Glens Falls Street Address Glens Falls Hospital
Wanner of Death Q Natural Cause []Accident ❑Homicide [3 Suicide ❑Undetermined ®Pending
Circumstances Investigation
us Medical Certifier Name Title
CI Gwendolyn Morris-Dickinson
Address
Death Certificate Filed District Number �� RegisterNumber
City(,Town or Village Glens Falls 1 i 1-1,
°Burial Date Cemetery or Crematory
8/16/2016 i Pine View Crematory
❑Entombment Address
OCremation `21 Quaker Road,Queensbury New York 12804
Date Place Removed
Z Q Removal and/or Held
and/or Address m -
Hold
I Date Point of
Q Transportation I Shipment
E by Common Destination
Carrier
- Date Cemetery Address
El Disinterment
Reinterment Date Cemetery Address
Permit Issued to ' Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 101079
Address
82 Broadway, Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped. If Other than Above
ME Address
CC
lei
a" Permission is hereby granted to dispose of the human remains described above as Indicated.
Date Issued iS ( 15 //6 Registrar of Vital Statistics ( C.,4-' Q Y _ `
District Number 5 to J Place 6 (ems F \A s /Ill y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition S/4,(11, Place of Disposition 2ncCw✓ , iipi'do._ '
(address)
(sedan) / get number) C (grave number)
1 Name of Sexton or Person in Charge of Premises arc L' Jtwit
ILI
( s*art
Signature s-I Title OZEMbilait-
(over)
DOH-1555 (02/2004)