Mandwelle, Jeanne NEW YORK STATE DEPARTMENT OF HEALTH' — ' v -It I \3
Vital Records Section Burial - Transit Permit
? y.a Name First Middle Last Sex
Jeanne (Crandell) Mandwelle Female
STV Date of Death Age If Veteran of U.S. Armed Forces,
sl"_= February 28, 2013 91 War or Dates i CI �j- 0143
N: Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 10 Jerome Avenue
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 1-1 Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
4 Christopher D. Hoy, M.D. Dr.
Address
-€ � 102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number RegisterNumber
City, Town or Village 5 Sy
❑Burial i Date D�j��i 3 Cemetery or Crematory
4,9 / Pine View Crematory
0 �"❑Entombment A
®Cremation 're s
uarer Road Queensbury,NY 12804
02 Date Place Removed
❑ Removal and/or Held Pine View Crematory
and/or Address
Hold Quaker Road Queensbury,NY 12804
Date Point of
illiTransportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
��El 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
Address
I,:,
,:U Permission is hereby granted to dispose of the human remains descri ed abo�(�e_as i mate
Registrar of Vital Statistics fJ'
Date Issued �, y.�-ut� 9 ���
(signature)
r District Number S2b� Place (-..( ,a�u
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ) i,-(3 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
. (section) (lot number) (grave number)
, Name of Sexton or Per on in Charge f Premises 6 tq 31.mal
(please print)
Signature Title � �`0C.,
(over)
DOH-1555 (02/2004)