Holcomb, Elizaabeth NEW YORK STATE DEPARTMENT OF HEALTH ,.
Vital Records Section Burial - TransiPermit
P
E
a : Name First . Middle Last Sex
Elizabeth Ann Holcomb Female
Date of Death Age If Veteran of U.S. Armed Forces,
t4
January 26, 2014 92 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Greenwich Street Address 68 Fort Miller Road
Manner of Death Fri Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
• Circumstances Investigation
Medical Certifier Name Title
Julia Malin,
" Address
418 Geyser Road Suite 14 Ballston Spa, NY 12020
Death Certificate Filed District Number
Register Number
City, Town or Village Greenwich 5
❑Burial Date Cemetery or Crematory
January 28, 2014 Pine View Crematory
I ❑Entombment Address
its®
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 01079
Address
82 Broadway, Fort Edward NY 12828
4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereb granted to dispose of the human re ins described abov as indicated.
Date Issued 02-6 �1{- Registrar of Vital Statistics 44
(signature)
District Number 5(757 Place I (fl )l'i ()-F ig r?encv/CIi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
' " Date of Disposition 01/28/2014 Place of Disposition Quaker Road Queensbury,NY 12804
R;; (address)
m (section) (lot number) (grave number)
dr,:itripi-
T Name of Sexton or Perso. in Charge Premises St Kaki
(please print)
Signature
�f'
, Title Li7.dtfi r�l(
(over)
DOH-1555 (02/2004)