Deyoe, Irene NEW YORK STATE DEPARTMENT OF HEALTH tt 7Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
w. Irene Gertrude Deyoe Female
-_ Date of Death Age If Veteran of U.S. Armed Forces,
February 5, 2013 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death X❑ Natural Cause ❑ Accident 0 Homicide ❑ Suicide n Undetermined ri❑ Pending
Circumstances Investigation
- 5 Medical Certifier Name Title
Maureen Hyland,
Address
9 Carey Road Queensbury, NY 12804
er
< - Death Certificate Filed District Number f. Register Number
Ci , Town or Village Fort Edward
❑Burial Date Cemetery or Crematory
"*- Februa 7, 2013 Pine View Cremato
❑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
3 Carrier
' ` Date Cemetery Address
❑ Disinterment
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Sz Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
r
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 her by anted to dispose of the human ns.describe boy as indicated.
Date Issue j� J.� Registrar of Vital Statisti
(signature)
District Number] 7 Place Ja A
LR I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/07/2013 Place of Disposition Quaker Road Queensbury,NY 12804
"-`- (address)
• (section) (lot number) S (grave number)
•
Name of Sexton or Per n in Char•a of Premises EL Lit �;a`"4tt
( please print)
Signature L ' .... Title CQAv^p'tOd-
(over)
DOH-1555 (02/2004)