Ely, Gwladys NEW YORK STATE DEPARTMENT OF HEALTH { : ! : IV g
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gwladys Ely Female
w Date of Death Age If Veteran of U.S. Armed Forces,
"' .- October 22, 2013 96 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Indian River Health Care Facility
Manner of Death X❑ Natural Cause 0 Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
a' Medical Certifier Name Title
` Jennifer Hayes,
es-A-
,.,.° Address
'W 17 Madison Street Granville, NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village 57T� 3 c
❑Burial Date Cemetery or Crematory
October 23, 2013 Pine View Crematory
❑Entombment Address
t:®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑
Removal
and/or and/or Held
Hold Address
Date Point of
_F❑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 01077
Address
123 Main St., Argyle NY 12809
-; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
d$
1' Permission is hereby granted to dispose of the human remains des s • ' - s indicated.
~� Date Issued 101231 13 Registrar of Vital Statistics l Airway
` (signature)
District Number E7 5 Place VI `r l--3,-(�.LkUtl
f = ( --
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t Date of Disposition 10/23/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in harge of P emises r J1 -S „+E4/+
(pl ase print)
Signature Title Clgil►9
(over)
DOH-1555 (02/2004)