Corbett, Helen 1 N it s(,Z
NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen R. Corbett Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 29, 2014 96 _ War or Dates
Place of Death Hospital, Institution or
L City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death n Natural Cause ❑ Accident ❑ Homicide D Suicide ❑ El Pending
Circumstances Investigation
Medical Certifier Name Title
Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
Death Certificate Filed District Number Register Nu ber
tt.`! City, Town or Village Fort Edward `7_�j 5 6
❑Burial Date Cemetery or Crematory
September 2, 2014 Pine View Crematory
0 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
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
44 82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
' Address
Permission is re y grant d to dispose of the human r• LI s describ d abovre as in 'cated.
Date Issued f Registrar of Vital Statistics v `�/lJ V
.�� �� signature)
District Number 5i 55 Place 1 o W & 0-6 L' aim
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/02/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) ( number) c (grave number)
Name of Sexton or Person in Charge of Premises ir'°t •'` .lt'��'
(pleas punt)
Signature (uI Title Cik OWE
(over)
DOH-1555 (02/2004)