Merrill, Llah NEW YORK STATE DEPARTMENT OF HEALTH 11 } L U
Vital Records Section do Burial - Tan Permit
Name First Middle Last Sex
Ilah Mary Merrill Female
Date of Death Age If Veteran of U.S. Armed Forces,
f May 12, 2013 80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death J Natural Cause 0 Accident Homicide Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Matthew Miles, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 6 D 1 2-1 0
❑Burial Date Cemetery or Crematory
May 16, 2013 Pine View Crematory
F❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
it, Date Place Removed
Removal and/or Held
and/or Address
' Hold
Date Point of
tom:'❑Transportation Shipment
by Common Destination
Carrier
ib Disinterment
Date Cemetery Address
}
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
, : Address
00,
123 Main St., Argyle NY 12809
. Name of Funeral Firm Making Disposition or to Whom
.'_ Remains are Shipped, If Other than Above
Address
11) Permission is hereby granted to dispose of the human remains described above as indic ted.
Date Issued 31 /3 / i3 Registrar of Vital Statistics LA-)cd-& -
(signature)
,:, District Number 5 6 C i Place CO S ,\S / A-) ' t 2�U I
ws g I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/16/2013 Place of Disposition Quaker Road Queensbury,NY 12804
,.r.n
(address)
(section) (lot number)c (grave number)
Name of Sexton or Person in harge of Premises
rl J n(sif
, ( lease print)
Signatures4 Title Ceieriti -
(over)
DOH-1555 (02/2004)
I