Houlihan, Marie NEW YORK STATE DEPARTMENT OF HEALTH t 31
Vital Records Section Ili . _ k Burial - Transit Permit
Name First Middle Last Sex
Marie Houlihan Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 16, 2012 79 War or Dates
, Place of Death Hospital, Institution or
rn City, Town or Village Hudson Falls Street Address 9 Cherry Street
ak Manner of DeathEjNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
t Medical Certifier Name Title
Robert Sponzo, Dr.
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village son F a_11-c ,.7a L
❑ Date Burial j 0 l I Q )ZQ 12 Cemetery or Crematory
❑Entombment V1 I U f Pine View Crematory
'ssAddress uucr Road Queensbury,NY 12804
ry';h®Cremation ry�
,P Date Place Removed
❑ Removal
and/or and/or Held Pine View Crematory
Hold Address
Quaker Road Queensbury,NY 12804
Date Point of
! ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Iy Permit Issued to Registration Number
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
Remains are Shipped, If Other than Above
Address
> • Permission is hereby granted to dispose of the human remains described above as indicated.
Registrarof Vital Statistics
Date Issued ��/�'ga/�- �• /r1a_4-,L.,
(signature)
District Number 6746 Place jf ' / /-A-e-i-i, 17 *CI c
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Wri lft Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
'M. Name of Sexton or P 'n Charge of Premises F� ti Cfa
ot ► Q W
ri
(please print)
Perso
�i))....... GURII-rep,
• SignatureTitle
(over)
DOH-1555 (02/2004)