Healey, Anna NEW YORK STATE DEPARTMENT OF HEALTH J
Vital Records Section _ '► Burial - Transit Permit
t-
Name First Middle Last Sex
Anna Ruth Healey Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 13, 2012 82 War or Dates
Place of Death Hospital, Institution or
.. City, Town or Village Glens Falls Stre t Address Glens Falls Hospital
Manner of Death X❑ Natural Cause ❑ Accident ❑ Hoicide ❑ Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
. Medical Certifier Name Title
® Matthew Varughese, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District t14be Regiit Number
City, Town or Village c j_ O5
❑Burial Date Cemetery or Crematoryre
March 20, 2012 Southside Cemetery
❑Entombment Address
®Cremation Route 32 Town of Moreau South Glens Falls,NY 12803
Date Place Removed
❑ Removal
and/or and/or Held
Hold Address
Date Point of
1❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
-1 a❑ Reinterment
Date Cemetery Address
ro Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Y- Name of Funeral Firm Making Disposition or to Whom
is Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains descr' e a ov in ' e .
Date Issued D3 iJ 2Df2--Registrar of Vital Statistics 1�
_ (signature)
District Number 5(�0� Place 7 A, A)
I certify that the remains of the decedent identified above Ner disposed of in accordance with this permit on:
rlt v 4.w Crewrakor&c1 r✓►
Date of Disposition 03/20/2012 Place of Disposition Route 32 Town of Moreau South Glens FaIIs,NY 12803
. (address)
(section)em- �on (lot number) (grave number)
Name of Sexton or Person in Charg f Premises 1 l7;104-l+ v - /Q--
r (please pent)
°.. Signature�� 1 Title C `
(over)
DOH-1555 (02/2004)