Sholes, Mary NEW YORK STATE DEPARTMENT OF HEALTH r -. t 4-51
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Jacquelyn Sholes Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 22, 2014 87 War or Dates
- Place of Death Hospital, Institution or
$_ City, Town or Village Glens Falls Street Address Glens Falls Hospital
� .
Manner of Deathin] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
j Circumstances Investigation
Medical Certifier Name Title
Michael Miles,
t,
-kk; Address
100 Park Street Glens Falls, NY 12801
77 Death Certificate Filed District Number„— �� i Register N umber
City, Town or Village Glens Falls )l G}.(�
❑Burial Date Cemetery or Crematory
January424, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
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
_t Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
tiF Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
k Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 /Z (-I Jil Registrar of Vital Statistics WC.A ..
(signature)
District Number 5 b O ) Place 6 ,,S , I,S S. Al y
', I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/24/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature Title
(over)
DOH-1555 (02/2004)