Hart, Louise NEW YORK STATE DEPARTMENT OF HEALTH -* - * 44Lc
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
14,
Louise Kay Hart Female
Date of Death Age If Veteran of U.S. Armed Forces,
.. September 7, 2015 76 War or Dates
a Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 49 Prospect Street
Manner of Death Natural Cause ❑ Accident 0 Homicide ❑ Suicide 1-1 Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
AgeelA. Gillani, M.D. Dr.
- Address
" . 102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls rj CC I LI '3
❑Burial Date Cemetery or Crematory
September 11, 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
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
timt Permit Issued to Registration Number
.. Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
4
Address
44,
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.
Date Issued 9 )$ //5 Registrar of Vital Statistics 1,O e
a (signature)
rit District Number 5-�� 1 Place o -S • \,\S Li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/11/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
t Name of Sexton or Person i Charge o Premises fits-411„._ Si ariti
please print)
Signature Title AKIAATA (over)
DOH-1555 (02/2004)