Archambault, Isabel r ^ s NEW YORK STATE DEPARTMENT OF HEALTH T'�{
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Isabel P. Archambault F
Date of Death 1 1 /0 6/2 01 5 7 0 Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Moreau Street Address 180 Butler Rd.
faManner of Death❑x Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined Pending
Circumstances Investigation
Ill Medical Certifier Name Title
p Michael Sikirica MD
Address 50 Broad St, Waterford,NY 12188
Death Certificate Filed District r Regist tuber
City, Town or Village Moreau Cf
❑Burial Date 1 1 /09/201 5 Cemetery or Crematory Pine View Crematory
❑Entombment Address
EiCremation 21 Quaker Rd, Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
o and/or Address
E Hold
N Date Point of
e ❑Transportation Shipment
0 by Common Destination
• Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
III Reinterment
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01 078
Address 136 Main Street, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
w
a. Permission is her by rannto dispose of the human remains scribed o e as indicated.
Date Issued Q Z ! Registrar of Vital Statistics
(si re)
District Number (itg Place �C? CI v� doA,(r kw /o12
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition ll/io fir Place of Disposition £N�,., 1' i tore.--
I (address)
(section) [ (lot number) r, (grave number)
0 Name of Sexton or Person in Charge f Premises ���,�fi ^^itr
z ( lease print)
Signature Title to -a
T
(over)
DOH-1555 (02/2004)