Carruthers, Stephanie NEW YORK STATE DEPARTMENT OF HEALT" 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Stephanie P Carruthers Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 19, 2014 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Fri
v..i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
_ Medical Certifier Name Title
Timothy E. Murphy, Mr.
Address
52 Haviland Avenue Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
} City, Town or Village Glens Falls S 6c9( 2ei 0
Sp❑Burial Date Cemetery or Crematory
June 25, 2014 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
w❑ Removal Date Place Removed
and/or Held
and/or Address
Hold
Date Point of
I I Transportation Shipment
by Common Destination
`, Carrier
mt.' Date Cemetery Address
. ❑ Disinterment
1
Reinterment Date Cemetery Address
;; Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
11 123 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 remains described above as indicated.
Registrar of Vital Statistics
Date Issued 6 � Z 3�/i-/ tA3 C wJ,/\-55A-V-
(signature)
,40 District Number ' 60 i Place s U \ '5 , W y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/25/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) t umber (grave number)
zi Name of Sexton' = so • harge of Premises
(please pri t) +
Signature V.
_ . i Title C(L�4yi l) SZ-- i4 j •
(over)
DOH-1555 (02/2004)