Tarzia, Doris NEW YORK STATE DEPARTMENT OF HEALTIkI . . -t A 30
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Doris Jean TAr7iA Female
j - Date of Death 0 5/1 8/2 01 5 Age 1 0 0 If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Glens Falls Hospital, Institution or
City, Town or Village Street Address The Pines
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ElSuicide ❑ Undetermined ❑ Pending
- Circumstances Investigation
Medical Certifier Name IA \,, I� Title r
Qc
I:: Address R c5-_t�- `r\It\ / ous\ b�s�
Death Certificate Filed District Number Register Number
4 City, Town or Village ���SS A -57,09 / ,5-6
-oo
El Burial Date 0 5/1 8/2 01 5 Cemetery or Crematory Pine View Crematory
❑Entombment Address 21
- ®Cremation Quaker Rd. Queensbury, NY 12804
Date Place Removed
❑ Removal and/or Held
i. and/or Address
Hold
Date Point of
.1 ❑Transportation Shipment
by Common Destination
; E< Carrier
1 ❑ Disinterment
Date Cemetery Address
ElReinterment Date Cemetery Address
N
Permit Issued to MB Kilmer Funeral Home O1 Registration Number
Name of Funeral Home -7
Address 82 Broadway Fort Edward, NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is her by granted to dispose of the human - -- scribed •ove as Intl' - i.
Date Issued Kam/— Registrar of Vital Statistics _ _ O� II
l� F _( i Ggna )
District NumberC Place I
11
I certify that the remains of the decedent identified abov- ere disposed of inaccordant with this permit on:
Date of Disposition SJ if f t r Place of Disposition 1 LL (v.-'tr.,.
(address)
I .. (section) (lot number) (grave number)
si, Name of Sexton or Person in Char a of Premises i- ,('r+vy""1
(please print)
Si nature Title /IZf-Ml4l't
g
(over)
DOH-1555 (02/2004)