Cary, Susanna it.
NEW YORK STATE DEPARTMENT OF HEALTH / zre
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
p q Susanna B. Cary Female
Date of Death Age If Veteran of U.S. Armed Forces,
L, May 17, 2012 88 War or Dates
} Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Pleasant Valley
Manner of Death Natural Cause 0 Accident D Homicide 0 Suicide 0 Undetermined Pending
,_ Circumstances Investigation
Medical Certifier Name Title
Edit Masaba, MD Dr.
Address
200 Main Street Greenwich, NY 12834
y Death Certificate Filed District Number 6 75O Register Nu x r
City, Town or Village Argyle
`0 Burial Date Cemetery or Crematory
May 18, 2012 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
:-,❑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 01077
f ` Address 0
123 Main St., Argyle NY 12809
itt Name of Funeral Firm Making Disposition or to Whom
,1 Remains are Shipped, If Other than Above
Address
Permission is er y granted to dispose of the human re a'ns described above as indicated.
II ' ��� ��
ih Date Issued Registrar of Vital Statistics Q�Q ed C v
(signature)
District Number Place
_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/18/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /J'
(lot number) r (grave number)
°. Name of Sexton or Pers n in Charge f Premises t nst ( thnld-
(please print)
Signature i k, Title MOM-UDC
(over)
DOH-1555 (02/2004)