Layhee, Evely NEW YORK STATE DEPARTMENT OF HEALTH # 7$8
Vital Records Section Burial -.Transit Permit
Name First Middle Last Sex
Evelyn June Layhee Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 30, 2015 82 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Street Address Sar la Hospital
0 Manner of Death X❑Ili Natural Cause ❑ Accident ❑ Homicide ❑ Suicide Undetermined ❑ Pending
o ` Circumstances Investigation
0LU Medical Certifier Name Title
Donald R. Sheeley, M.D. Dr
Address
211 Church Street Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
November 2, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
E Hold
fA Date Point of
cL ❑Transportation Shipment
CA by Common Destination
O Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
5 Address
re
W:
IL, Permission is h re y granted to dispose of the human rem s de cr d at r indicat .
Date Issued I� l�;) Registrar of Vital Statistics
(signature)
District Number 4150 ( Place
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I Date of Disposition 11/02/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
0)
Ce (section) At (lot number) (grave number)
p Name of Sexton or Person in Char a of Premises !fir„ £ •—
Z (please print)
W Signature Title ►npg
(over)
DOH-1555 (02/2004)