Williamson, Rachel NEW YORK STATE DEPARTMENT OF HEALTH . '` 5-7 I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rachael J. Williamson Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/03/2015 99 years War or Dates
Place of Death Hospital, Institution or
City, Tg )0090C Saratoga Springs Street Address Weasley Health Care Center
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide D Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Rick D. Teetz M. D.
Address
131 Lawrence Street, Saratoga Springs N Y
Death Certificate Filed District Number Register Number
City, T900(9(MINX Saratoga Springs 4501 385
El Burial Date Cemetery or Crematory
Entombment 08/05/2015 Pine View Crematory
Address
[Cremation Queensbury, N Y
Date Place Removed
Z1-1
Removal and/or Held
and/or Address
Hold
0 Date Point of
N ['Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.b. Kilmer Funeral Home 01077
Address
136 Main Street, South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
II- Remains are Shipped, If Other than Above
2 Address
Q
W
Permission is hereby granted to dispose of the human rema. cr' ed abwe indicat d.
Date Issued 08/05/2015 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Q)bdjc Place of Disposition ,., v , `rd afi4)4
(address)
LU
N
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises t sRi1 St "
Z (please print)
W Signature t /b Title 1 AViVt
(over)
DOH-1555 (02/2004)