Secci, Anna NEW YORK STATE DEPARTMENT OF HEALTH # I / 0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anna Mae Secci Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 16, 2015 91 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death1=1 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof, M.D. Dr.
Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Nu_ ber ter Number
City, Town or Village Queensbury (vS -1 C)
❑Burial Date Cemetery or Crematory
March 17, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
E Hold
CO Date Point of
A. ❑Transportation Shipment
by Common Destination
.0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Renterment
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
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
ZS Address
fr
W
a" Permission is hereby granted to dispose of the human r ns described q3oilie as indicated.
Date Issued )'1 j aplRegistrar of Vital Statistics CA, 14
(signature)
District Numbera. c rl Place ) Q Of Q —( ;v f
I certify that the remains of the decedent identified above were disposed of in accorda ce w. h this permit on:
Date of Disposition 03/17/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
i
Name of Sexton or Person in Char a of Premises r I m c ci R I^vy E(If
(please print)
Signature Title Cif'e ,K{C:y AS;+
T
(over)
DOH-1555 (02/2004)