Cowart, Judith NEW YORK STATE DEPARTMENT OF HEALTH # i'i5Vital Records Sectionburial - Transi ermit
Name First Middle Last Sex
Judith Cowart Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 22, 2013 83 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 245 Easton Station Road
Manner of Death Natural Cause n Accident ri Homicide n Suicide n Undetermined ri❑ Pending
ELI Circumstances Investigation
Medical Certifier Name Title
Kevin Costello, Dr.
Address
1 Pinnacle Place MC 58 Albany, NY 12203
Death Certificate Filed District Number 51 �3 Register Number
City, Town or Village 5A'
['Burial Date Cemetery or Crematory
January 23, 2013 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
HOId
Date Point of
�.0 Transportation Shipment
0 by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
D Reinterment
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 IAddress
Permission is ereby ranted to dispose of the human re ains described above as indicated.
Date Issued / Registrar of Vital Statistic
_ (signature)
s'District Number�9 3 Place / 0--e....,---x. yam.
V
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
Date of Disposition 01/23/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
t , (section) ( t number) (grave number)
Name of Sexto r Pe n i ge of remises
ovj-)
(please print)
1
Signatur Title
(over)
DOH-1555 (02/2004)