Churchill, Ruth NEW YORK STATE DEPARTMENT OF HEALTH f z ��i .
Vital Records Section Burial - Transit Permit
777
,„, Name First Middle Last Sex
Ruth Shirley Churchill Female
t' Date of Death Age If Veteran of U.S. Armed Forces,
zii
, September 23, 2014 84 War or Dates
meµ Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide n Suicide ❑ Undetermined ❑ Pending
ft Circumstances Investigation
Medical Certifier Name Title
N Kenneth Lance,
Address
9 Carey Road Queensbury, NY 12804
l.""-cli Death Certificate Filed District Number Registerumber
City, Town or Village Fort Edward 515 Fj
❑Burial Date Cemetery or Crematory
oft September 24, 2014 Pine View Crematory
' ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
n- Date Place Removed
and/or Held
and/or Address
Hold
URemoval
Hold
Date Point of
., ❑Transportation Shipment
by Common Destination
Carrier
l ❑ Disinterment
Date Cemetery Address
ElReinterment Date Cemetery Address
fltPermit Issued to Registration Number
. s Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
ft
ft 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 hereby granted to dispose of the human re 'ns describ d above s ' dicated.
Date Issued q Ia41, Registrar of Vital Statistics V p
I -., ,�,-,�,, 1 (signature)
-.` .. (6 1�v Lt District Number 6155 Place i ( 1.1M EUAw
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/24/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) �`
t t, (lot number) (grave number)
a Name of Sexton or Person in Charge f Premises ost S"^
, , d ,(please print)
. Signature Si nature Title CW'rrah
(over)
DOH-1555 (02/2004)