Ricciardelli, Betty NEW YORK STATE DEPARTMENT OF HEAL. _ I "i l
Vital Records Section Burial - Tran it Permit
Iii Name First Middle Last Sex
petty W. n_icci i: del1.i Female
iiii Date of Death Age If Veteran of U.S. Armed Forces,
Feb. 22 2013 77 War or Dates NO
Place of Death Hospital, Institution or
j City, Town or Village City of Glens Falls Glens Falls Hospital
Bi g Street Address pi
Manner of Death Lxi1771Natural Cause 0 Accident D Homicide D Suicide E Undetermined r7 Pending
ttt Circumstances Investigation
Medical Certifier Name Title
Shahid Ahmed MD
Address
102 Park St. Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village City of Glens Pails ,)7,0/ 7e,
Date Cemetery or Crematory
❑Burial Feb. 25, 2013 Pine View Creamtory
Address
®Cremation 21 Quaker Road Queensburv, New York 12804
Date Place Removed
❑Removal and/or Held
•`• and/or Address
aHold
Date Point of
N0 Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
>s Permit Issued to P. Kilmer Funeral Homer Home Registration Number
M. P
Name of Funeral Home
Aig Address
136 Main St. South G1 ens Fall' New York 12801
Name of Funeral Firm Making Disposition or to Whom,
: " Remains are Shipped, If Other than Above
. Address
Ati
Permission is hereby granted to dispose of the human remains described ab ve dicated.
g?>' Date Issued 2-25-1 3 Registrar of Vital Statistics
si of re
( 9na )
Si District Number
�j�Q/ Place City of Glens Falls, New York 12801
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
f
E Date of Disposition a6"?6 Place of Disposition //VC IhA✓ 0.409-••144/44-07ty
2 (address)
LU
U3
Ce (section) 4 Knu/rbe (grave number)
`'Name of Sexton e n in Charge of Premises G.
g (please pnnt P
lU Signature Title C '191/7I1 , -
(over)
DOH-1555 (9/98)