Clearwater, Stephanie 4 NEW YORK STATE DEPARTMENT OF HEALTH tt` C_
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex
_; Stephanie Lynn Clearwater Female
4 Date of Death Age If Veteran of U.S. Armed Forces,
April 27, 2012 40 War or Dates
=; Place of Death Hospital, Institution or
City, Town or Village Street Address Sly Pond Road
Manner of Death Natural Cause 1=1 Accident 1=1 Homicide 0 Suicide El Undetermined ri Pending
Circumstances Investigation
_' Medical Certifier Name Title
Michael Sikirica,
Address
50 Broad Street Waterford, NY 12188
Death cate Filed /� District Number Register u ber
� City. o, • = Village "���11/}.i✓� ."� l��
❑Burial Date Cemetery or Crematory
May 1, 2012 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
-. Removal and/or Held
and/or Address
- Hold
Date Point of
0 Transportation Shipment
by Common Destination
'' Carrier
❑ Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
.46
Permit Issued to Registration Number
ft Name of Funeral Home M. B. Kilmer Funeral Home 01096
0. Address
123 Main St., Argyle NY 12809
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 rema' described above. indica ed.
Date Issued _ U� /ti
Registrar of Vital Statistics ijcf
1 d
(signature)
District Numbe - Place Z_ �?
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
Date of Disposition 05/01/2012 Place of Disposition Quaker Road Queensbury,NY 12804
4i (address)
_ (section) (lot number) (grave number)
C
Name of Sexton or Pers n in Charg of Premises h,ir number)(
(please print)
Signature 14Title attn 0i.
(over)
DOH-1555 (02/2004)
1