Stanley, Carol NEW YORK STATE DEPARTMENT OF HEALTH # ?U
Vital Records Section ,_N Burial - Transit Permit
Name First Middle Last Sex
Carol Ann Sta1Py FPma1c _
.. Date of Death Age If Veteran of U.S. Armed Forces,
4/1 9/1 2 71 War or Dates No
}- Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
a Manner of Death kfig Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined r i Pending
Circumstances Investigation
ILI Medical Certifier Name Title
flE De,smond R_ DplGiarro MT)
Address
59 Myrtle avenue, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs
❑Burial Date Cemetery or Crematory
QEntombment 4/23/12 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or Address
F Hold
0 Date Point of
M. Trans ortation
❑ p Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
T. Name of Funeral Home M.B. Kilmer Funeral Home 01 078
Address
136 Main St. So.Glnes Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
f- Remains are Shipped, If Other than Above
2 Address
C
iti
a. Permission is hereby granted to dispose of the human remai es ib ab a - dicated.
Date Issued 4/22/1 2 Registrar of Vital Statistics
(signature)
District Number 4 :'r Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition y 1 70 it Place of Disposition 1'L trui Cwncfork,,.
ILI
2 (address)
L0
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises G nr,-,� J,,,,f'r'
.+fir (please print)
1 1 Signature Title akin prT09.,
(over)
DOH-1555 (02/2004)