Liapes, Carol NEW YORK STATE DEPARTMENT OF HEALTH
7-)(6,
Vital Records Section i • Burial - Transit Permit
-' Name First Middle Last Sex
Carol Annabel) Liapes Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 11, 2013 74 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 11 Newcome Street
At.z Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson,
Address
. : 161 Carey Road Queensbury, NY 12804
„r Death Certificate Filed District Number Register Number
r ; City, Town or Village c(S 7 Si
❑Burial Date Cemetery or Crematory
22,_ May 14, 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
5 Carrier
F Disinterment Date Cemetery Address
t 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
Permission is hereby granted to dispose of the human remai s des ibed a v as indicated.
Registrar of Vital Statistics
Date Issued . -/y-..it 9
(signature)
District Number 470.j---7 Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/14/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
.' 4
(section) 4 (lot number) S (grave number)
Name of Sexton or Person in Charge of Premises I A t:Yi J t" tk
(please print) ..-��,��
� : Signature Title ( i'1'G�J►�
(over)
DOH-1555 (02/2004)