Kemmer, Helen Ci Z?i
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
N
T Name First Middle Last Sex
Helen Kemmer 1 Female
: Date of Death Age If Veteran of U.S. Armed Forces,
April 29, 2012 89 War or Dates
e:: Place of Death Hospital, Institution or
.Z' City, Town or Village Glens Falls ; Street Address Glens Falls Hospital
AJIS
in Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
113 Circumstances Investigation
Medical Certifier Name Title
4' Michael Adams,MD
Address
1448 Route 9, South Glens Falls,NY 12828
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 /q0
❑Burial Date Cemetery or Crematory
May 1, 2012 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
F' Hold
co
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home ___I 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
:M Remains are Shipped, If Other than Above
I Address
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Permission is hereby granted to dispose of the human remains describb ab ve in d.
Date Issued Q p/ZG/2-- Registrar of Vital Statistics �
/ (signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 513 AIL Place of Disposition FiqUuc,i r( etof t�
2 (address)
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CO
CL
0 (section) ,(lot number) (grave number)
0p Name of Sexton or Person in Charge Premises ithTk Kr L��+rlti
Z (please print)
W Signature G��L
9 9— Title `titre t1 r� Vt
(over)
DOH-1555(02/2004)