Graham, Bonita NEW YORK STATE DEPARTMENT OF HEALTH -tt I I'2_(/y)-
Vital Records Section Burial - Transit ' ermit
77-77
•;, _ Name First Middle Last Sex
Bonita Graham Female
Date of Death Age If Veteran of U.S. Armed Forces,
1,0 October 8, 2014 66 War or Dates
: Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
. ;: Circumstances Investigation
`. Medical Certifier Name Title
� �a
Timothy Murphy,
Address
- 52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number ��� Register Number
City, Town or Village Glens Falls t-I��Ci
. Date Cemeteryor Crematory
0Burial
October 9, 2014 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
ElDisinterment Date Cemetery Address
IllReinterment 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
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
fir= Address
Permission is hereby grante to dispose of the humak remai described above as i icate .
,- Date Issued D 1 Registrar of Vital Statistics P�.y} 17)
(signature)
District Number -"AGO / Place A-K-7Y �� [_,
1
a I certify that the remains of the decedent identified above ere disposed of in accordance ith this permit on:
Date of Disposition 10/0/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) Abt nu er) (grave number)
Name of Sextor a P; sj r in Charge of Premises c _ d
, (please rint) /
Signatur-.o
. 4l Title �;J t
(over)
DOH-1555 (02/2004)