Cavanaugh, Alberta NEW YORK STATE DEPARTMENT OF HEALTH 1c
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alberta Xionne Cavanaugh Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 12, 2012 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines of Glens Falls
Manner of Death Natural Cause ❑ Accident ❑ Homicide Suicide ❑ Undetermined ❑ Pending
4 Circumstances Investigation
Medical Certifier Name Title
0 Bernardo R Villajuan, Dr.
Address
48 East Street Fort Edward, NY 12828
Death Certificate Filed District Number �� 1 Register Number �'{, City, Town or Village
❑Burial Date Cemetery or Crematory
February 15, 2012 Pine View Cemetery
0 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
Date Cemetery Address
❑ Disinterment
ElReinterment 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 descri i�J • -d.
Date Issued /y,ZU/z"Registrar of Vital Statistics4ayve
/�
/ (signature)
District Number ,)_ �6O/ Place ‘ P.bo AY/S, XX
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fE Date of Disposition 02/15/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
a (section) / (lot number)r (grave number)
• Name of Sexton or Person in Char of Premises l hr1S4�1t l "6'yr\r('�
(please print)
iii AL
Signature Title 02E096017
(over)
DOH-1555 (02/2004)