Bruce, JoAnn NEW YORK STATE DEPARTMENT OF HEALTH E I // 33(.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jo Ann Bruce Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 5, 2015 77 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death .i Natural Cause ❑ Accident E Homicide ❑ Suicide n Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number $
City,Town or Village Glens Falls D601 G�J
,. Date Cemetery or Crematory
❑Burial May 6, 2015 Pine View Crematory
`'' ❑Entombment Address
- ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
e and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Y.` Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
` Permission is hereby ranted to dispose of the human remains desc 2ed.;po
-�� Date Issued C7Sl�6 ?�,i3— Registrars i ed.
of Vital Statistics � l/�- ->e,
(signature)
District Number 5 6O/ Place 1. j_//` /t-X
: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Fr Date of Disposition 05/06/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
:'
€ . (section) (lot nu er) (grave number)
,, 9 .+P}`
art, Name of Sexton or Person in Char f Premises l ^�_��
,/�; (please pent)
Signature v Title (O t1 7
(over)
DOH-1555 (02/2004)