Bradshaw, Eula NEW YORK STATE DEPARTMENT OF HEALTH • ji"
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eula May Bradshaw Female
°° Date of Death Age If Veteran of U.S. Armed Forces,
October 14, 2014 83 War or Dates
I
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 61 Lamplighter Acres
Manner of Death Natural Cause El Accident ❑ Homicide ❑ Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Sheryl Salerno,
Address
4 Carey Road Queensbury, NY 12804
';' Death Certificate Filed District Number Register Number
..Y City, Town or Village Moreau
❑Burial Date Cemetery or Crematory
October 17, 2014 Pine View Crematory
l❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ 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 01078
Address
136 Main Street, South Glens Falls NY 12803
'. Name of Funeral Firm Making Disposition or to Whom
L. Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
c
°- o Registrar of Vital Statistics ', ! �,,i - ,4,, rA.�—L
Date Issued / j/fo f/'� (signature)
District Number 956,2 Place 557 ,ecy46iaes de4'. 44ewe,4c,, /, 8 a'
/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/17/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) r� (grave number)
Name of Sexton or Person in Charge of Premises ,i(yP4,� �01%44
A (please print)
�� /.�Signature - Title " +'l_
(over)
DOH-1555 (02/2004)