LaBarge, Gloria NEW YORK STATE DEPARTMENT OF HEALTH u b
Vital Records Section t - 144 Burial - Transit Permit
I Name First Middle Last Sex
8,4
04 Gloria Jean LaBarge Female
' Date of Death Age If Veteran of U.S. Armed Forces,
i. March 28, 2012 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Mary Clariesse Kilayko, Dr.
aft Address
Death Certificate Filed District Number �0 Register Numb?ri / , .
City, Town or Village4.
"T
❑Burial Date Cemetery or Crematory
March 30, 2012 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Hold Address
Date Point of
❑Transportation Shipment
'r- by Common
Destination
a Carrier
4 � Disinterment
Date Cemetery Address
i.
tr 0 Reinterment Date Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
t 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as 'ndicated.
iN
Date Issued 3 �� a��zRe 9�istrar of Vital Statistics �pt.At)-.Q (Al
(signature
District Number 560 t Place 6 s \ 1 S T JV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/30/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) I (lot number) c^ (grave number)
Name of Sexton or Pers•n in Charge •-f Premises iri lir- `)t"rtd{-
r (please print)
Signature �� Title � 'A�r� .
(over)
DOH-1555 (02/2004)