France, Sr. Richard NEW YORK STATE DEPARTMENT OF HEALTH 4 0
Vital Records Section 1 4 Burial - Transit Permit
Name First Middle Last Sex
Richard Erwin France, Sr. Female
Date of Death Age If Veteran of U.S.Armed Forces,
December 4, 2012 86 War or Dates Yes 1944-1946
I— Place of Death Hospital, Institution
WCity,Town or Village City of Albany or Street Address Albany Medical Center
0 Manner of Death Natural El ❑ Pending
14.1 ® Accident ❑ Homicide ❑ Suicide
Cause Circumstances Investigation
8 Medical Certifier Name Title
i3 Paul L. Marra Coroner
Address
112 State Street, Albany, NY 12207
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 2264
Date Cemetery or Crematory
❑ Burial December 6, 2012 Pine View Crematory
El Entombment Address
® Cremation
Queensbury, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or
H Hold Address
in
Date Point of
a Transportation Shipment
U) ❑ By Common Carrier Destination
ai
❑ Date Cemetery Address
Disinterment
ElDate Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. KilmeiFuneral Home 01078
Address
136 Main Street, So. Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z' Address
II,L
d Permission is hereby granted to dispose of the human remains described abo a'seindicated.
Date December 5, 2012 Registrar of Vital Statistics �-` "�G / II
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in ac
dance with this permit on:
Z Date of Disposition 12-7-11- Place of Disposition ►rtugl J arevidflu,s-
WW (address)
W
u)
�' (section) (tot number) (grave number)
0
Ci
c /41.gQ � tw Name of Sexton or Person in Char a of Premisesi
(please print)
Signature /441--- . Title C 601/
(over)
DOH-1555 (02/2004)