Creaser, Concetta NEW YORK STATE DEPARTMENT OF HEALTH 4 SO
Vital Records Section _ Burial - Transit Permit
Name First Middle Last Sex
Concetta Creaser Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 26, 2012 70 • War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 25 Old Bend Road
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
.1 Medical Certifier Name Title
a Dr. Eric Pillemer,
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number 5co 1 Register N_�u Uer
City, Town or Village Moreau `!S
J-.❑Burial Date Cemetery or Crematory
September 28, 2012 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
1 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
s
_; Permission is hereby granted to dispose of the human remai described above Las,indicated.
Date Issued 1/v?�//:z. Registrar of Vital Statistics 1-
(signature)
s—'
District Number .16 4�, Place %? 0-flV '
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/28/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) - (lotberr)1 (grave number)
Name of Sexton or erson in C rge of Premises AiS e J¢ita,
< (please print)
— Signature Title eteMl`iti
(over)
DOH-1555 (02/2004)