Lampmon, Donna NEW YORK STATE DEPARTMENT OF HEALTH . .._,, inyt
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donna Lee Lampmon Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 12, 2015 48 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause n Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
C9 Circumstances Investigation
N. Medical Certifier Name Title
John Esper, Dr.
Address
325 Main Street Hudson Falls, NY 12839
Death Certificate Filed District Number ���I Register Number L 7j6�
City, Town or Village Glens Falls `
:�1,❑Burial Date Cemetery or Crematory
. October 14, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment
Date Cemetery Address
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
3Remains are Shipped, If Other than Above
Address
W
IL" Permission is hereby granted to dispose of the huma remains cribed a ove as indi ated
Date Issued m !� �Q�S Registrar of Vital Statistics -."in- �� L
I f 1 ! i ture)
�n
�w �i/� t/_-/�
District Number / Place � � `
I certify that the remains of the decedent identified above were disposed of in accordance with this per it on:
fl Date of Disposition 10/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
411
Et (section) ��' (lot number) (grave number)
Name of Sexton or Pe:Lon in Ch rge of Premises t'lr,, Se►i4-
I ( lease print)
Signature Title iitAa'
9
(over)
DOH-1555 (02/2004)