Havens, Helen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
% Name First Middle Last Sex
Helen Komsa Havens Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 08E ,2014 85 War or Dates
Place of Death Ulster Hospital, Institution or
City, Town or Village Street Address Northeast Center for Special Care
Manner of DeathIL.Natural Cause Accident Homicide Suicide 0 Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
,` Dr. Christopher B. Melcer MD
Address
i,x 300 Grant Ave, Lake Katrine, NY 12449
r e; Death Certificate Filed District Number Register Number
._: City, Town or Village Town 5567 31
''a;❑Burial Date Cemetery or Crematory
March 09, 2014 Pine View Crematory
❑Entombment Address
t ®Cremation Queensbury, NY
k Date Place Removed
ri I--'Removal and/or Held
and/or Address
Hold
. ,i Date Point of
❑Transportation Shipment
by Common Destination
y=' Carrier —
s Date Cemetery Address
❑Disinterment
IfE'
: Reinterment Date Cemetery Address
" Permit Issued to Registration Number
I Name of Funeral Home M.B. Kilmer Funneral Home 01079
Address
_. 82 Broadway, Fort Edward, NY 01079
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
X. Address
IX
Permission is hereby granted to dispose of the human remain escribed above as indicated.
Date Issued April 08,2014 Registrar of Vital Statistics ,, cature)
District Number 5567 Place Town of Ulster
OA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11 W pW My Place of Disposition '[inbi+J C► rw
(address)
(section) '� (Iqt number) (grave number)
4, Name of Sexton or Per n in Charge f Premises Ye�„
as a� ^�-
( ee print}
Signature Title Cr7,e> il,
(over)
DOH-1555 (02/2004)