Imrie, Doris NEW YORK STATE DEPARTMENT OF HEALTH r -- f 3l1
Vital Records Section Burial - Transit Permit
e, Name First Middle Last Sex
Doris Patricia Imrie Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 25, 2015 92 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 ❑ Accident ri Homicide ❑ Suicide ❑ Undetermined � Pending
Circumstances Investigation
Medical Certifier Name Title
Barney Rubenstein, Dr.
Address
.. = 33 Gilbert St. Cambridge, NY 12816
Death Certificate Filed District Number _,� t Regis— �f�yrrb�r
City, Town or Village Glens Falls ��(1y�1 �a
.❑Burial Date Cemetery or Crematory
April 28, 2015 Pine View Crematory
`ElEntombment 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
n Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
,. Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 07
ri tt
Address 1 ,3
ovwkia, wo p � ) I 1q
a Name of Funeral Firm Making Dispositin or to Whom
: Remains are Shipped, If Other than Above
Address
F Permission is hereby granted to dispose of the human remains de c r/ rve icated.
Date Issued 00-8/2zo>s Registrar of Vital Statistics /
A'/4.
(signature)
District Number �o/ Place l ►lls, ,GX
-a,F; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
elr Date of Disposition 04/28/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) 4 (lot number)c (grave number)
Name of Sexton or Person in Charge of Premises �{ t
jf ( ease print)
C / ►1 Al
ax,- Signature %► Title .t.,
(over)
DOH-1555 (02/2004)