McIntosh, Marilyn NEW YORK STATE DEPARTMENT OF HEALTH if Z,3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marilyn McIntosh Female
Date of Death Age If Veteran of U.S. Armed Forces,
. January 8, 2015 63 War or Dates
, Place of Death Hospital, Institution or City, Town or Village Kingsbury Street Address 1734 Hinds Road
Manner of Death n Natural Cause X❑ Accident El Homicide ❑ Suicide 0 Undetermined In❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Sikirica MD, Dr.
Y Address
Death Certificate Filed District Number Register Number
City, Town or Village Kingsbury 54 0 /
0 Burial Date Cemetery or Crematory
January 12, 2015 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Qteensbury,NY 12804
Date Place Removed
17 Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
=1- Ill
Reinterment Date Cemetery Address
f. Permit Issued to Registration Number
4 Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
.g 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- 1 A A O / S� Registrar of Vital Statistics V L3.4.3 t-'�
(signature)
District Number 5-0L` Place in ,it c �;,wl5�-r.u.;..�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/12/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) v(lot number) (grave number)
Name of Sexton or Person i Charge of Premises Save,
( lease print)
Si nature • 4 Title �t g
9
al
(over)
DOH-1555 (02/2004)