Baldwin, Barbara NEW YORK STATE DEPARTMENT OF HEALTI# ''
Vital Records Section Burial - TransitPermit
77
Name First Middle Last Sex
Barbara Jean Baldwin Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 30, 2012 80 War or Dates
, Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 1.7r1 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
' Medical Certifier Name Title
Daniel C. Larson, M.D. Dr.
4' Address
4 Broad Street Glen Falls, NY 12801
Death Certificate Filed District Number Register Number
,ten City, Town or Village Glens Falls �� � 603
❑Burial Date Cemetery or Crematory
January 3, 2013 Pine View Crematory
t❑Entombment Address
MCremation. Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
t Hold
Date Point of
• ❑Transportation Shipment
by Common Destination
`` Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
P• ermit Issued to Registration Number
Ac-
Name of Funeral Home M.B. Kilmer Funeral Home 01078
A• ddress
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 desc :cam edo as ' ted.
Date Issued O!4 2/20/3 Registrar of Vital Statistics
�
(signature)
1,1 District Number .)60/ Place ,
qi I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/03/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
number)d (lot (grave number)
'• ' Name of Sexton or Person in Charge of Premises r,S , n
r411-
(please print)
Signature Title Citicrot-V 2
(over)
DOH-1555 (02/2004)