Butterfield, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH r�
Vital Records Section Burial - Tra sit Permit
Name First Middle Last Sex
Kathleen F. Butterfield Female
Date of Death Age I If Veteran of U.S.Armed Forces,
04/24/2012 63 War or Dates WWII
I— Place of Death Hospital, Institution
W City,Town or Village City of Albany or Street Address Albany Medical Center Hospital
a Manner of Death ® Natural ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Cause Circumstances Investigation
V Medical Certifier Name Title
p' John-Robert La Porta MD
Address
AMCH 43 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 829
Date Cemetery or Crematory
❑ Burial 04/26/2012 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date ' Place Removed
Z Removal and/or Held
0 ❑ and/or Address
' Hold
co
0 Date Point of
a Transportation Shipment
CO ❑ By Common El Carrier Destination
III Disinterment
Date Cemetery Address
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main St. So. Glens Falls, NY 12803
F- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
a- Permission is hereby granted to dispose of the human remains described above as i dic to
Date 04/25/2012 Registrar of Vital Statistics nicb t - 110-0 V D-1
Issued (signature) Syv
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 14in i(t Place of Disposition Pi wA)Lt,J CrAtetort~...
w (address)
w
0 (section) (lot number) (grave number)
Z Name of Sexton or Person in Charge of Premises A t�J 5�
w (please print)
Signature gii7L. Title CRA in Tine-
(over)
DOH-1555 (02/2004)