Mercurae, Brenda tt
NEW YORK STATE DEPARTMENT OF HEALTH f . `` Burial - Transit ''t/ /Permit
Vital Records Section
Name First Middle Last Sex
Brenda Mercure Female
Date of Death Age If Veteran of U.S.Armed Forces,
August 14, 2013 62 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 2 Gilmore Ave
Manner of Death Natural Cause Ei Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
g
Dr. Eric Pillemer,
Address
6,4 w
100 Park Street Glens Falls, NY 12801
44 Death Certificate Filed District Number Register Nu tuber
City, Town or Village c2 S7 1
• 0 Burial Date Cemetery or Crematory
August 16, 2013 Pine View Crematory
❑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
"`0 Reinterment
a 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
1 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 remai es ibed above as in icated.
4,. Registrar of Vital Statistics A-
t, Date Issued e l) l
(signature)
District Number �(o 5-- Place 0i� „,6.E.,3S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/16/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) . (tot number)c (grave number)
Name of Sexton or Person i Charge of P emises L it+r toOkitt
'(please print)
Signature L Title Mftc1
(over)
DOH-1555 (02/2004)