Reynolds, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH ' CO1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kathleen Mary Reynolds Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 15, 2015 68 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ai Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Kyle Leonard, Dr.
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number O RegisteNumber
Ci , Town or Village Glens Falls
" '❑Burial Date Cemetery or Crematory
February 18, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbu ,NY 12804
❑ Removal Date Place Removed
ri and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
,ar .
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
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 2-/( `1 0.5 Registrar of Vital Statistics k., )
(signature
District Number 3 6 0 j Place 6 G2A" s- FcA \ 5 /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/18/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) A (lot number) , (grave number)
Name of Sexton or Person in Cha ge of Premises G�i�, 3u+4rr
( lease print)
Signature Title Milm+YP-
(over)
DOH-1555 (02/2004)