Weeks, Debbie NEW YORK STATE DEPARTMENT OF HEALTH ft # 113
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Debbie Weeks Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 20, 2014 53 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
John P. Stoutenburg, Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number I Register Number
City, Town or Village Glens Falls
.❑Burial Date Cemetery or Crematory
March 24, 2014 Pine View Crematory
- ❑Entombmentam% Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
. � Removal and/or Held
and/or Address
Hold
1-1 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
�r. ❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
` Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 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
i
Permission is hereby rante to dispose of the human rem ns descr" ed above�s indicate .
Date Issued icy Registrar of Vital Statistics Q'(� p,,y-, /1/_ "'2
(signature)
District Number 6l�0lf Place CL J--gdJ
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
TT Date of Disposition 03/24/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) A (lot number (grave number)
el
Name of Sexton or Person in Charge of Premises
,1r fnnl�j`
//i (please print)
' Signature Title fikriffitt,
(over)
DOH-1555 (02/2004)