Angus, Loretta NEW YORK STATE DEPARTMENT OF HEALTH * l3�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Loretta Mary . Angus Female
Date of Death Age If Veteran of U.S. Armed Forces,
2/2 9/1 5 8 6 War or Dates No
1 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Illy Circumstances Investigation
tu Medical Certifier Name Title
Michael Miles MD
Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 1 0 6
❑Burial Date - Cemetery or Crematory
Entombment 2/27/15 Pine View Crematory
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2❑and/or
Address
U)
Hold
Date Point of
Di 0 Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01 078
ffi Address
136 Main St. So. Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
1-04 Remains are Shipped, If Other than Above
Address
UI
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2/'7.--6 / /5 Registrar of Vital Statistics CA.' Y-,-S1
(signature)
District Number Soo Place (, ,,-5 G `\ ) nj
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition :313115 Place of Disposition a) ( —
(address)
U
U)
(section) (lot number) (grave number)
a
ti Name of Sexton or Person in Charge of Premises 1144 LS444 t
r (please print)
IL/ A
Signature L. Title aZ4tAf
(over)
DOH-1555 (02/2004)