Hammond, Lorraine NEW YORK STATE DEPARTMENT OF HEALTH 111
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lorraine Hammond Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 30, 2013 52 War or Dates
Place of Death Hospital, Institution or \
City, Town or Village Kingsbury Street s 411464
d)C Ft ')
Manner of Death Natural Cause ❑ Accident ❑ HomicideAddres Suicide
Maynard Street n Undetermined Ei 1---I Pending
0 CircumstancesInvestigation
Medical Certifier Name Title
Darci Ann Gaiotti-Grubbs, M.D Dr.
Address
102 Park Street Glens Falls, NY 12801
Imo- Death Certificate Filed District Number Register Number
City, Town or Village . 74 v2 5
❑Burial Date Cemetery or Crematory
April 1, 2013 Pine View Crematory
❑Entombment •
Address
®Cremation C.luaKer Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held Pine View Crematory
and/or Address
Hold Quaker Road Queensbury,NY 12804
tO Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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 remai es ribed above as indicated.
Date Issued 'j�'l-2o/-.3 Registrar of Vital Statistics ' LA.342.ag-i-J—-c
(signature)
District Numbei 57(, a. Place ���-� J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/01/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number (grave number)
g. Name of Sexton or Perso in Charge of Premises 1lbsi(1 1" edn1H'
(please print)
Signature L 1" Title C M1 O1?_.
(over)
DOH-1555 (02/2004)