Bean, Shirley NEW YORK STATE DEPARTMENT OF HEALTH 1 + # ``X
Vital Records Section Burial - Transit Permit
r Name First 'W Middle Last Sex
Shirley Ann Bean Female
Date of Death Age If Veteran of U.S.Armed Forces,
''1-3 06/30/2016 67 War or Dates No
}- Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address Albany Medical Center
0 Manner of Death Natural El
Undetermined ❑ Pending
W ❑ Cause ® El Homicide ❑ SuicideCircumstances Investigation
W Medical Certifier Name Title
pl Jeffrey D. Hubbard MD
Address
112 State St. Albany, NY 12207
` Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1359
Date Cemetery or Crematory
El Burial 07/05/2016 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
0' ❑ and/or Address
17 Hold
CO
Q, Date Point of
O.' Transportation Shipment
CD ❑ By Common Destination
a Carrier
❑ Date Cemetery Address
Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main St. South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Itj
a. Permission is hereby granted to dispose of the human remains destnbe ove as indicated
Date 07/01/2016 Registrar of Vital Statistics
Issued c .� �__,��
(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition l'S'(L Place of Disposition gl1/E.....
L (address)
w'
v
Ce (section) ic
number) (grave number)
0
g Si
II
Name of Sexton or Person in Char a of Premises �
w (please print)
Signature c Title Ca 6 �ilfZ
(over)
DOH-1555 (02/2004)