Bailey-Copeland, Martha NEW YORK STATE DEPARTMENT OF HEALTH 51
Vital Records Section a �. Burial - Transit Permit
Name First Middle Last Sex
Martha Jane Bailey-Copeland Female
Date of Death Age If Veteran of U.S. Armed Forces,
t= November 29, 2014 87 War or Dates
Place of Death / Hospital, Institution or
Pr' Ci• ty, Town or Village C7- (/r/l' Street Address Indian River Health Care Facility
Manner of Death Natural Cause 0 Accident El Homicide 0 Suicide 0 Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
_ Sean Bain, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Registtr Number
City, Town or Village 6j22nu,i fe_ 7v3L5
44 0 Burial Date Cemetery or Crematory
December 2, 2014 Pine View Crematory
0 Entombment Address
1-4
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
s
Date Point of
0 Transportation Shipment
by Common Destination
ig.1 Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
A• ddress
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 hereb ranted to dispose of the human remain es+crib . .o e as indicated.
' Date Issued /' i / Registrar of Vital Statistics ,V. ' a li c��
r (signature)
•District Number 57 i Place 5i7L /i%// /1{f J0 ,�
I certify that the remains of the decedent identified above were/disposed of in accordance with this permit on:
'f Date of Disposition 12/02/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
' = (section) f (lot number) _ (grave number)
Name of Sexton or Pers n in Charge of Premises i 4,4.' 3.^.. ,f
( ease print)
S• ignature �/�✓ .4— Title Croc-0410.1
(over)
DOH-1555 (02/2004)