Fleming, Carol NEW YORK STATE DEPARTMENT OF HEALTH i
Vital Records Section Burial - Trantn r ermit
Name First Middle Last Sex
�' Carol B Fleming Female
:;!,i4 Date of Death Age If Veteran of U.S. Armed Forces,
gas June 10, 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 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier , T1110
,
rt r SS
/"
Qraikkly L' ("1/Z
Death Certificate Filed District Numbgr��/ Register �
��City, Town or Village Glens Falls
4 ❑Burial Date Cemetery or Crematory
e June 16, 2014 Pine View Crematory
❑
g, Entombment
4 Address
1 ,:ECremation Quaker Road Queensbury,NY 12804
v Date Place Removed
❑ Removal and/or Held
and/or Address
- Hold
*s
Date Point of
❑Transportation Shipment
by Common Destination
r
Carrier
Disinterment Date Cemetery Address
kV
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
4 Name of Funeral Firm Making Disposition or to Whom
_: Remains are Shipped, If Other than Above
Address
Permission is hereb ranted to dispose of the human remains describ bo a as ' dic e
Date Issued 6/Z 2ofy Registrar of Vital Statistics
(signature)
District Number U/ Place 6/&j" /cr ' sj rOf /2 O/
fgt:, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
:, 4 Date of Disposition 06/16/2014 Place of Disposition Quaker Road Queensbury,NY 12804
Vt. (address)
(section) number) (grave number)
". Name of Sexton or Person 'n Charge of Premises d(lot
i.►"'�.�`n'/" �" `r��
°F__ (pi print)
�T Signature Title CM trirt
(over)
DOH-1555 (02/2004)