West, Dolores NEW YORK STATE DEPARTMENT OF HEALTH 1
4 5 0
Vital Records Section . Burial - Transit Permit
Name First Middle Last Sex
Dolores West Female
Zikri Date of Death Age If Veteran of U.S. Armed Forces,
June 4, 2013 88 War or Dates
Place of Death Hospital, Institution or
i. City, Town or Village Street Address The Orchard Nursing & Rehabilitation Cent
Manner of Deathl7r1
E.i Natural Cause LI Accident i l Homicide El Suicide ElUndetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
SE.AN V%Vnv ALL ''01;)
Address
-T5 I DgTvt 5rt. GgPNVtLL1i N`[ 1z �2
Death ificate Filed District Number Register Number
,AV,..,-
City, T wn r Village GgAIvI V tLLE 5 7540 `I
(7
'0 Burial Date Cemetery or Crematory
June 7, 2013 Pine View
0 Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
L -L 0 Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
`i Carrier
Disinterment Date Cemetery Address
a Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
lfe Address
£- 82 Broadway, Fort Edward NY 12828
ri 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 abovett as indicated.
i Date Issued 06 /o(.0 AO 0 Registrar of Vital Statistics d�twu�tt1"V CtA.Y )
(signature)
u District Number 575(0 Place ¶rbWtU 0 ? 6-leAjd,LL
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/07/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
', Name of Sexton or Pers in Charge o Premises d,r1 s -- L�{,tt
(ilease print)
Signature Title rafiii-o2
(over)
DOH-1555 (02/2004)