LeMaire, Sally NEW YORK STATE DEPARTMENT OF HEALTH . ' if I
t
Vital Records Section Burial - Transit rermit
777
Name First Middle Last Sex
Sally Jean LeMaire Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 20, 2014 62 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death D Natural Cause Di Accident 0 Homicide n Suicide � Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Adams, Dr.
.. Address
10154 Saratoga Raod Fort Edward, NY 12828
Death Certificate Filed District Numbl��� Registerjp Nyber
City, Town or Village Glens Falls .5 Y $
0 Burial Date Cemetery or Crematory
March 25, 2014 Pine View Crematory
0 Entombment Address
< w®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Wit' Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
17 0Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
al 82 Broadway, Fort Edward NY 12828
7. Name of Funeral Firm Making Disposition or to Whom
" Remains are Shipped, If Other than Above
Address4 Permission is hereby granted to dispose of the human remains descri a ov s ' ated.
Date Issued 3//a �p/v Registrar of Vital Statistics /� ,i
l �� (signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/25/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
� (section) (lot numb'
number (grave number)
Name of Sexton or Perso in Charg of Premises
,„ (please print)
Signature Title GU'rtt-74
(over)
DOH-1555 (02/2004)