Hall, Maria lk
NEW YORK STATE DEPARTMENT OF HEALTbI 1..f T 132-
Vital Records Section 4. Burial - Transit rermit
Name First
Middle Last Sex
Maria Hall Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/08/2013 84 years War or Dates
f4 Place of Death Hospital, Institution or
Ei City, To )/i X Glens Falls Street Address Park St CIRns Falls, N Y 12801
WManner° eath Natural Cause ❑Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
Circumstances Investigation
uj Medical Certifier Name Title
Noelle Stevens M n
Address
100 Broad Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
Mi City, Towbefiliklitxx Glens Falls 5601 100
> ❑Burial Date Cemetery or Crematory
❑Entombment 03/11/2013 Pine View Crematorium
Address
Ni❑Cremation QuePnshury, NY 12804 _
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
w`rii Hold
Date Point of
❑Transportation Shipment
E by Common Destination
Carrier
11
❑Disinterment Date Cemetery Address
❑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, N Y 12803
IDI Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
2
L
fl Permission is hereby granted to dispose of the human remains described above as indicated.
mii Date Issued Registrar of Vital Statistics '
03/11/2013 9 �C7t.J�1�Y� W ^
(signature)
District Number Place '
5601 Glens Falls f
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
Ili Date of Disposition 1'/(/3 Place of Disposition Rai t 1/iJ ehrz/
a (a dr
L
w
CC (section) ��� � (lot num�e� (grave number)
Name of Sexto L�r P rso in C arge of Premises �"J �1'
/ (please print)
Signature Title C �' _ 4t r, --r.
(over)
DOH-1555 (02/2004)