Donaldson, Janet i -Ze
NEW YORK STATE DEPARTMENT OF HEALTH .� -
Vital Records Section - * Burial - Transit Permit
Name First Middle Last Sex
Janet H. Donaldson Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 7, 2012 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death IL.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Farhana Kamal, M.D. Dr.
Address
100 Park Street Glens Falls, NY 1280101 �C i
Death Certificate Filed District N`,lbl J 1 Regis�r[Number
City, Town or Village U
❑Burial Date Cemetery or Crematory
March 8, 2012 Pine View
❑Entombment Address
; ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
g Hold
Date Point of
❑Transportation Shipment
by Common Destination
14 Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
.44 Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued .. 18 /r Z Registrar of Vital Statistics mac' '4z
(signature)
District Number g 6.& I Place 6 5va IS ,No
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
- Date of Disposition 03/08/2012 Place of Disposition Quaker Road Queensbury,NY 12804
` (address)
11
a (section) (lot number) (grave number)
ft_ Name of Sexton or Pers n in Charge o remises /14.111.1r J(0
please print)
CM M t -
`
- Signature !'o` Title� t
(over)
DOH-1555 (02/2004)