Riley, Leatha •
NEW YORK STATE DEPARTMENT OF HEALTH- " 1, gli�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Leatha Mae Riley Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 29, 2015 83 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Fort Edward Street Address 40 McIntyre Street Apt 5
CI Manner of Death X❑ Natural Cause ❑ Accident E Homicide ❑ Suicide ❑ Undetermined ❑ Pending
111
Circumstances Investigation
in Medical Certifier Name Title
Michael Fuller, Dr.
Address
East Street Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5"]�'"`I
0 Burial Date Cemetery or Crematory
December 1, 2015 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
fht Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z. Address
O. Permission is hereby rirnnted to dispose of the human r ins d scribed ab ve 1dicated.
Date Issue 1;}1 top 6 Registrar of Vital Statistics J
� , (signatur
District Number 6155 Place �('fj,( 1 F L
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/01/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
CZ (section) (lot number) (grave number)
0 0 Name of Sexton or Person in Charge;f Premises :' S
(pl ase print)
iii Signature vvc i • Title citfotaft
(over)
2004)