McIntyre, Mona NEW YORK STATE DEPARTMENT OF HEALTH t '1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mona Mane McIntyre Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/12/2013 80 years War or Dates
-pi...,. Place of Death Hospital, Institution or
1.5 City, Tow15056 illSIRXX Glens Falls Street Address Glens Falls Hospital
W Manner of Death W Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Ct
Suzanne M Rayeski M D
Address
170 Warren Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, TowyCR�YiIIXX Glens Falls 5601 538
DBurial Date Cemetery or Crematory
DEntombment 12/16/2013 Pine View Cemetery
Address
1; mation Ouoensburv, NY 12804
Date Place Removed
Z Removal and/or Held
❑and/or
Address
it Hold
Ul
0 Date Point of
Q Transportation Shipment
G1 by Common Destination
Carrier
D Disinterment Date Cemetery Address
D Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward. NY f.) tA,
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped, If Other than Above
Address
tatty
lid
Permission is hereby granted to dispose of the human remains described above as i icated.
Date Issued 19/16 0013 Registrar of Vital Statistics '
(signa re)
District Number Place
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lint Date of Disposition is ft410 Place of Disposition ,ryVft� � irtn--
(address)
IAI
Ul
ir (section) r (lot number)(" (grave number)
Name of Sexton or Person in Charge of Pre ises (0i). r M,•df
Z 74L,
(plkase print)lit Signature Title af 1}flla
(over)
O0H-1555 (02/2004)