Treulieb, Alta NEW YORK STATE DEPARTMENT OF HEALTH ` ' if �y
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alta Ruth Treulieb Female
Date of Death Age If Veteran of U.S. Armed Forces,
:, January 25, 2014 83 _ War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death E Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined 1-1❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls
7 ❑Burial Date Cemetery or Crematory
January 27, 2014 Pine View Crematory
,. ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
4 Date Place Removed
❑ Removal and/or Held
and/or Address
Hold Quaker Road Queensbury,NY 12804
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
,p 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
r- Remains are Shipped, If Other than Above
Address
Permission 4 is h reb granted to dispose of the hums remains d ribed ab a as indicat
.
Date Issued p( / Registrar of Vital Statistics
signature)
District Number / Place _,p Q_ -
I certify that the remains of the decedent identified above were disposed of in accordanc with this permit on:
r Date of Disposition 01/27/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numberd— (grave number)
J
Name of Sexton or Person in Char a of Premises 414,, PhwP(
(please print)
:° Signature4 Title « ""� a
(over)
DOH-1555 (02/2004)