Klass, Audrey NEW YORK STATE DEPARTMENT OF HEALTH 7Z
Vital Records Section Burial - Transit Permit
ri Name First Middle Last Sex
Audrey Klass Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 19, 2014 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address Home of The Good Shepherd
Manner of Death Natural Cause Accident Homicide ri Suicide 0 Undetermined r7 Pending
Circumstances Investigation
* Medical Certifier Name Title
Glen Anderson,
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
Ci , Town or Villa a Moreau Cs' 3 y
❑Burial Date Cemetery or Crematory
November 24, 2014 Pine View Crematory
0 Entombment Address
MCremation Quaker Road Queensbury,NY 12804
. m' Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
no Reinterment Date Cemetery Address
;t 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
1 Permission is hereby granted to dispose of the human re ains described above as indicated.
9Jif 4 ' ((Jet/Ii --
Date Issued l//dy��y Registrar of Vital Statistics
(signature)
District Number I/5 j, Place 5c/ X C,40/cis / l)/ 4-Tit: 71cf,C e q� /AJ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
u Date of Disposition 11/24/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /� (lot number (grave number)
Name of Sexton or Person in Char a of Premises C''��e'lyl:— &4?
! A
(please print)
Signature Title Ci&''I Ift1r'+�
(over)
DOH-1555(02/2004)