Ryan, Tash NEW Y1ORK SATE DEPARTMENT OF HEALTH !OCs
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tasha Michele Lee Ryan Female
Date of Death Age If Veteran of U.S. Armed Forces,
' December 18, 2015 42 War or Dates
,x Place of Death Hospital, Institution or
R' City, Town or Village Moreau Street Address 93 Feederdam Road
Manner of Death Natural Cause Ej Accident 0 Homicide Suicide Undetermined ri Pending
_ Circumstances Investigation
Ilt Medical Certifier Name Title
AgeelA. Gillani, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
_t Death Certificate Filed District� e Regist�umber
City, Town or Village Moreau t
❑Burial Date Cemetery or Crematory
December 21, 2015 Pine View Cremate
❑Entombment Address y
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
,::El Removal and/or Held
and/or Address
Hold
Date Point of
1 '0 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r= 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
31 Address
} Permission is hereby ranted to dispose of the human re escrib. ' a ve as indicated.
Date Issued Registrar of Vital Statistics /
�' gnature)
SQ c Place S / &L '.O/dS S ()'7uivicw,. i , 82-2
District Number� �
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
t z..,'z .7 p.) i e i C tie_ -o�y
T Date of Disposition 1 1/29-15 Place of Disposition Quaker Road Queensbury,NY 12$04
(address)
11
(section) (lot number) (grave number)
' Name of Sexton o 'n Charge of Premises _ -3�1.701-4 64-r✓/a.c-
(please print)
Signature Title
(over)
DOH-1555 (02/2004)