White, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH ft7�
Vital Records Section
• Burial - Transit ermit
Name First Middle Last Sex
Evelyn M. White Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 3, 2015 85 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 17 Oakwood Drive
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Mark Hoffman, Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Moreau `? 5 & 3- / 9
❑Burial Date Cemetery or Crematory
April 7, 2015 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
eL ❑Transportation Shipment
0 by Common Destination
O Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1--i/?// 5c Registrar of Vital Statistics .7)/ (;! '-
(signature)
District Number .-/ j(, Place /o w.'i o ( Mo,Gc &t& 3 51 /4 y,7o/d.) .' 0' /Xo a‘--
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
;: Date of Disposition 04/07/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
- (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises di p
9 (please print)
Signature �'C Title /it b4i V.:74,
T
(over)
DOH-1555 (02/2004)