Ostrom, Mary NEW YORK STATE DEPARTMENT OF HEALTH y i ) i L; Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Mary Isabella Ostrom Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 25, 2013 70 War or Dates
Place of Death Hospital, Institution or
4 ` City, Town or Village Moreau Street Address 2 Overlook Circle
oa. Manner of Death El Natural Cause ❑ Accident t l Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
uito Mark Hoffman, Dr.
Address
102 Park Street Glens Falls, NY 12801
o Death Certificate Filed District Number Register Number
City, Town or Village Moreau
t0 Burial Date Cemetery or Crematory
ro;; September 26, 2013 Pine View Crematory
U Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
{ ❑Transportation Shipment
by Common Destination
oso Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
"' Name of Funeral Home M.B. Kilmer Funeral Home 01078
` Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remai described above indicated,
Date Issued 9-al6-/3 Registrar of Vital Statistics /'a t ..a— g /`- u _
(signature)
District Number 44402_, Place o UAsi '
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1.0 Date of Disposition 09/26/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
1-
(section) 4(lot number) (grave number)
Name of Sexton or Perso in Charge Premises it Sp"'Mr
(p ase print)
7 C1 '
- Signature Title
(over)
DOH-1555 (02/2004)