Mingo, Alice NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alice Mary Mingo Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 2, 2014 87 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Fri Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Howard E. Silverberg, Dr.
Address
318 Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register Nlimber
City, Town or Village Glens Falls J6,17 /70
❑Burial Date Cemetery or Crematory
April 3, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
is. Removal and/or Held
0 and/or Address
Hold
O Date Point of
❑Transportation Shipment
▪ by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
4 ❑ Reinterment Date Cemetery Address
ry 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
Remains are Shipped, If Other than Above
Address
Permission is hereby,granted to dispose of the human remains describ d bo a in ' .
Date Issued 9 / , /yRegistrar of Vital Statistics
(signature)
District Number <_..5-6d/ Place 644/V5 AILS/ /t /a2 al
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
'''r': Date of Disposition 04/03/2014 Place of Disposition Quaker Road Queensbury,NY 12804 PftykdfrAieleeefidiy
(address)
(section) 5-609/11,mber)
(grave number)
Name of Sexton o rge ofPremises1 C
I (please p
Signature 'G+1 Title s
(over)
DOH-1555 (02/2004)