Canfield, Virginia NEW YORK STATE DEPARTMENT OF HEALTH._ - >l j 4
Vital Records Section Burial - Transit Permit
: Name First Middle Last Sex
Virginia L. Canfield Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 25, 2015 92 War or Dates
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 ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski, Dr.
Address
_ 170 Warren Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 6 o / 1 03
El Burial Date Cemetery or Crematory
y.,. February 26, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
r: ❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
' Carrier
1 ❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
f Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
LLB.`.
., 136 Main Street, South Glens Falls NY 12803
`P 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 4/ 2 6% 15 Registrar of Vital Statistics LA) cA.Ki y- �,rJ
(signature)
r
District Number 5 L p g Place 6 Csz�,.5 Ic,,k.\s i� Li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/26/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /i- (lot number) (grave number)
G Name of Sexton or Person in Charge of Premises ^AI __. ,--c-ftt
Z (Po lease print)
Signature Title 'E'14I
(over)
DOH-1555 (02/2004)