Ward, Gertrude NEW YORK STATE DEPARTMENT OF HEALTH 4-- . ft YOO
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gertrude Ward , Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 22, 2014 90 - War or Dates
' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death a Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Christopher D. Hoy, M.D. Dr.
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number GQ Register umber
City, Town or Village Glens Falls
0 Burial Date Cemetery or Crematory
December 23, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
4. Transportation Shipment
. by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
�= 123 Main St., Argyle NY 12809
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 1�1 2 3 / t� Registrar of Vital Statistics 6 � 5' \ S ,
r , (signature)
District Number [5GOf Place t v2,�,,hS \\ S i N y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w: Date of Disposition 12/23/2014 Place of Disposition Quaker Road Queensbury,NY 12804
tit (address)
M.
(section) (lot number) (grave number)
Name of Sexton or Personn Charge of Premises At--ase print)
Signature k Title ' ' !'t-
(over)
DOH-1555(02/2004)