Conlon, Donna NEW YORK STATE DEPARTMENT OF HEALTH viq 41. 54
Vital Records Section Burial - Transit Permit
— Name First Middle Last Sex
Donna Lee Conlon Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 15, 2013 65 War or Dates
ve of Death Hospital, Institution or
Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause El Accident ❑ Homicide Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Suzanne Blood, Dr.
Address
161 Carey Road Queensbury, NY 12804
war Death Certificate Filed District Number Register Number
ity Town or Village Glens Falls 566/
., Burial Date Cemetery or Crematory
January 16, 2013 Pine View Crematory
0 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
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
i l Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h reb granted to dispose of the human rains d cribed ab ve as ind' ated
Registrar of Vital Statistics e�1'J a. d '�
Date Issue g � ��-�'�"'
(signature)
District Number �eic/` Place 6/E�fi r/ 4 70V / /
? ; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/16/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /f ,(lot number) ,,, (grave number)
Name of Sexton or Person in Char a of Premises G I,ft ''Qnrt '
(p ase pent)
°I. Signature L Title eltlioncoi,
,-i-
(over)
DOH-1555 (02/2004)