Olmstead, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH • " 44 7L9
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth Olmsted Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 11, 2013 88 War or Dates
Place . I-ath __—,i Hospital, Institution or
Cit own 6 Villa•e ci 0 n aS'bu vCj Street Address Adirondack Tri-county Health Care Center
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ri Suicide 1-1 Undetermined El 1-1 Pending
CircumstancesInvestigation
1 Medical Certifier Name Title
Thomas Warrington RPA,
Address
112 Ski Bowl Road North Creek, NY 12853
Death Cegalcate Filed _ District Number �, Register Number 35
City,(own_or illade J 0 Pin% k u ,-
``` Burial Date Cemetery or Crematory
0 December 13 2013 Pine View Crematory
t 0 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
'' Carrier
Disinterment Date Cemetery Address
o`Y 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
.- Remains are Shipped, If Other than Above
..b Address
a Permission is hereby granted to dispose of the human remJ_Uc
'ns d scribed a • - as indicated.
Date Issued /off r 3//3 Registrar of Vital Statistics � e / a�,._
I (signature)
District Number $$ Place ic) 05 a;7 i-75 LL,,.-�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
? Date of Disposition 12/13/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
i
(section) (lot number) (grave number)
•
6,. a
Name of Sexton or Person in harge of Premises ,,4 VIA(
, A(
(please print)
IL Cefinl t�1�,
Signature yj Title
(over)
DOH-1555 (02/2004)