Rice, Vicki i Tt WO
NEW YORK STATE DEPARTMENT OF HEALTH r
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
- Vicki A. Rice Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 25, 2014 56 War or Dates
Place of Death Hospital, Institution or
-=. City, Town or Village Queensbury Street Address 82 Alpine Lane
Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined � Pending
Circumstances Investigation
: Medical Certifier Name Title
Timothy Murphy,
Address
- 52 Haviland Ave Glens Falls, NY 12801
;` Death Certificate Filed District Number Register Number
City, Town or Village Queensbury Sts6-1 --7q
❑Burial Date Cemetery or Crematory
June 30, 2014 Pine View Crematory
- ❑Entombment Address
1 Cremation Quaker Road Queensbury,NY 12804
-- Date Place Removed
".❑ Removal and/or Held
and/or Address
Hold
Date Point of
y❑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 01078
Address
4 136 Main Street, South Glens Falls NY 12803
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 re ins d scri ... - s i icated.
11110
Date Issued 6 a1 - l` .. Registrar of Vital Statistics D L
(signature)
District Number (A Place ''?(D 1_
...,
a
.-_,„
ii,.. I certify that the remains of the decedent identified alp. = were disposed of in ac rdanc with this permit on:
Date of Disposition 06/30/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) i (lot number) (grave number)
n
Name of Sexton or Person i Charge of Premises nsfi4w l
("lease print)
Signature Title C1' 1tN 4
(over)
DOH-1555 (02/2004)