Blood, Madeline NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - TransitAfr ermit
Name First Middle Last Sex
Madeline Jeanette Blood Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/14/2016 93 years War or Dates
I- Place of Death Hospital, Institution or
W City, TXXXXr gi( Glens Falls Street Address Glens Falls Hospital
is Manner of Death Natural Cause Accident u Homicide Suicide Undetermined Pending
US Circumstances Investigation
• Medical Certifier Name Title
O Thomas Portuese M B
Address
100 Broad Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, TAMOirXIXD410 Glens Falls 5601 - 205
El Burial Date Cemetery or Crematory
04/15/2016 Pine View Crematorium
❑Entombment Address
<; 2Cremation Queensbury, NY 12804
Date Place Removed
g❑Removal and/or Held
_ and/or Address
t Hold
Date Point of
Transportation Shipment
t��
G 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 01078
Address
82 Broadway Fort Edward, N Y 12828
iill Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX
iti
P` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/15/2016 Registrar of Vital Statistics lA)CAAdry.or
(signature)
gi District Number 5601 Place Glens Falls ',PL.(
_>;_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
la Date of Disposition itig6 Place of Disposition VOA-1)a._'; C".14"..,-
�,3`, (address)
Ul
iF�E
i (section) (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises ara Sfr,
Z (please print)
• Signature l6--� Title rtiVit kip
(over)
DOH-1555 (02/2004)