Lyke, Esther NEW YORK STATE DEPARTMENT OF HEALTH 41 3Cs.7
Vital Records Section Burial - Transit Permit
C Name First Middle Last Sex
Esther Josephine Lyke Female
Date of Death Age If Veteran of U.S. Armed Forces,
itRZ
June 29, 2013 84 War or Dates
_. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
ri Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined IT I--' Pending
CircumstancesInvestigation
Medical Certifier Name TitleNoelle Stevens, M.D. Dr.
re Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
q= Ci Town or Village Glens Falls 0101 2 Z
0 Burial Date Cemetery or Crematory
July 1, 2013 Pine View Crematory
k ❑Entombment Address
1, ®Cremation Quaker Road Queensbury,NY 12804
❑ Removal Date Place Removed
and/or and/or Held
Hold Address
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ 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 12828
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 remains described above a$ indicated.
Date Issued 7 / ) j 1,..3 Registrar of Vital Statistics 1.1•DC ....re W
(signature
District Number 5 60 I Place 6 LQtv.._s 1,\.s , N y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/01/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(lot number) (grave number)
Name of Sexton or P rson in Charge of Premises i4 r ?hNN'
(pl ase print)
43 Signature Title Criblfrfijait
(over)
DOH-1555 (02/2004)