Diamond, Janet NEW YORK STATE DEPARTMENT OF HEALTH • N # LI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Janet Ann Diamond Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 16, 2014 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Kingsbury Street Address 106 Queens Drive
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide Undetermined ❑ Pending
Circumstances Investigation
W.
Medical Certifier Name Title
Raji Sadal,
Address
2 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Kingsbury 5 76,Z
0 Burial Date Cemetery or Crematory
January 17, 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
❑ Disinterment Date Cemetery Address
;; ❑ 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
,' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number Place
" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/17/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
5 (section) ii (lot number) (grave number)
al Name of Sexton or Pers in Charg of Premises hr:l i IN.�6t
� lease print)
Signature Title aiirtfig
(over)
DOH-1555 (02/2004)