France, Patricia NEW YORK STATE DEPARTMENT OF HEALTH * ft �L 1
Vital Records Section Burial - Transit Permit
t
Name First Middle Last Sex
Patricia France Female
# Date of Death Age If Veteran of U.S. Armed Forces,
4.
August 8, 2013 89 War or Dates
Place of Death Hospital, Institution or
a City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death j Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Way, Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Numb ��' Register
,`N ber
Ci Town or Village Glens Falls
• ❑Burial Date Cemetery or Crematory
August 12, 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
Carrier
• ❑ Disinterment Date Cemetery Address
4 '❑ Reinterment Date Cemetery Address
4.
• 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
Permission is hereby granted to dispose of the human remains describedrye Ind' „AI_
/ Registrar of Vital Statistics
4 Date Issued O�/Z Z�/,3 9
(signature)
District Number 560/ Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/12/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) 1(lot number) (grave number)
Name of Sexton or Perso in Charge off remises t„+t
i� �""_ ( ease print)
Signature C Title 1N0Tc,--
(over)
DOH-1555 (02/2004)