Virgil, Shirley NEW YORK STATE DEPARTMENT OF HEALTH 41 13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
P Shirley Anne Virgil Female
k Date of Death Age If Veteran of U.S. Armed Forces,
February 6, 2013 77 War or Dates
Place of Death Hospital, Institution or
' City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
;` Medical Certifier Name Title
Derck W. Smith, f9
fM Address
Death Certificate Filed District Number t Register Number 5
Ci Town or Villa a Glens Falls
`.0 Burial Date Cemetery or Crematory
February 7, 2013 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
} ❑ Removal and/or Held
u and/or Address
' . Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
k ❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
s Permit Issued to Registration Number
n Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
v 136 Main Street, South Glens Falls NY 12803
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.
kJ Date Issued 216/13 Registrar of Vital Statistics L 3 cir-rNQ
(sign ture)
District Number 5"6 0 1 Place 6 �Uv�S I A l 1 S iv
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/07/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
0. ,
Name of Sexton or Person in Charge f Premises C i,s+0ii r 5MrtN'
(please print)
Signature AL.
Title cllC
(over)
DOH-1555 (02/2004)