Warden, Mary NEW YORK STATE DEPARTMEN i OF HtALTH �QQ
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Dayle-t onnell L j C A) F
Date of Death Age If Veteran of U.S. Armed Forces,
July 25, 2014 87 War or Dates
IH Place o ath Queensbury Hospital, Institution or
City oar Village Street Address 23 Brayton Lane
aManner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined ❑Pending
Circumstances Investigation
at Medical Certifier Name Title
p Christopher Hoy MD
Address
Carey Road HHHN, Queensbury, NY 12804
Death Certificate Filed July 28, 2014 District Number Register Number
City ow iir Village tj.0 5 1 9 i
❑Burial Date Cemetery or Crematory
July 29, 2014 Pine View Crematory •
• ii ['Entombment Address
Cremation 21 ()nicer Road, Queensbury, NY 12804
Date Place Removed
Removal and/or Held
is and/or Address
t Hold
Cl)
O Date Point of
tZ' Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address •
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01 078
Address
136 Main Street, South Glens Falls, Ny 12803
41 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Ir
IL
CL
]: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7/2 8/2 01 4 Registrar of Vital Statistics . l? A& KA� .,
(signature)
District Number al 5-1Place Queensbury, NY
I certify that the remains of the decedent identified above were disposed of in accord ce with this permit on:
tit• Date of Disposition g.-/V Place of Disposition 6;?ftrf: �j 4i h'C
(address)
in
tO
(section) (I umber)11 (grave number)
CI• Name of Sexton o er I -, .,rge of Premises L� "/1 /n
0 41: outi
,�► �r � � ate--119-441.4-1-e)e--
(please print)
la„„,„„, Signature F I Title {
(over)
DOH-1555 (02/2004)