Jeannette, Frances NEW YORK STATE DEPARTMENT OF HEALTH a p B S
Vital Records Section urial - Transit Permit
7 Name First Middle Last Sex
72-ter:
Frances Myrtle Jennette Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 25, 2014 85 War or Dates
t, Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death Natural Cause 0 Accident n Homicide D Suicide Undetermined Pending
Y Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof, M.D. Dr.
Address
` 100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
.. City, Town or Village Queensbury S l>.S 1 to 1
�-`0 Burial Date Cemetery or Crematory
August 29, 2014 Pine View Crematory
:-.'0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
M £K Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
`- by Common Destination
Carrier
Disinterment
Date Cemetery Address
0 Reinterment Date Cemetery Address
isi411 Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
iN Address
ffi 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
11:
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
-
1 Registrar of Vital Statistics . IZ .- -'mil`2CA-
Date Issued f a,� I y
(signature)
District Number S(j S 1 Place C7' et (1 S b y t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fi .; Date of Disposition 08/29/2014 Place of Disposition Quaker Road Queensbury,NY 12804
s (address)
-.`' (section) (lot number) (grave number)
`- Name of Sexton or Person in Charge of Premises
(please print)
�a_ Signature Title
(over)
DOH-1555 (02/2004)