Caprood, Rebecca NEW YORK STATE DEPARTMENT OF HEALTH e l # b S"
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rebecca Jean Caprood Female
;. Date of Death Age If Veteran of U.S. Armed Forces,
November 2, 2014 62 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident Homicide El Suicide riUndetermined Ei Pending
Circumstances Investigation
' Medical Certifier Name Title
Nawed A. Siddiqui, M.D. Dr.
446"4-
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
'. City, Town or Village Glens Falls
0 Burial Date Cemetery or Crematory
November 4, 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
❑Transportation Shipment
by Common Destination
` Carrier
0 Date Cemetery Address
Disinterment
$0 Reinterment
Date Cemetery Address
ig-
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
lir Address
't 136 Main Street, South Glens Falls NY 12803
ilt
14, 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.
Date Issued /i /4-I I% y Registrar of Vital Statistics C Y.i.Afi. t
(signature)
0 District Number 5 &C 1 Place 6 �s RAk\S N
J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11/04/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Per on in Charge of Premises C 4..it`flitV 1iiit,gi
(please print)
•
Signature Title (Oa 014ri(1
(over)
DOH-1555 (02/2004)