Gregory, Diane NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Diane L. Gregory Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 12, 2015 64 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Street Address 57 Martindale Ave
Manner of Death m
E.i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
James North, Dr.
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
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City, Town or Village 5 7 a 6
❑Burial Date Cemetery or Crematory
May 14, 2015 Pine View Crematory
❑Entombment
� Address
is®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
ElDisinterment Date Cemetery Address
❑ Renterment Date Cemetery Address
';a Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 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
sky
Permission is hereby granted to dispose of the human remains descri ed above as indicated.
%.,A, Date Issued s -l4 l S Registrar of Vital Statistics 7 < ',-,. (1 >
(signature)
District Number 5-7 ,C PlaceTails
I certify that the remains of the decedent identified abo were disposed of in accordance with this permit on:
Date of Disposition 05/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
CO
(section) lot number) (grave number)
a Name of Sexto P Charge of Premises ,-ecie>.-P ,J )ice c
/m4 (please pipt)
, Signatur AV C-"` Title T•
—
- (over)
DOH-1555 (02/2004)