Robillard, Margaret if-
NEW YORK STATE DEPARTMENT OF HEALTH. .. 5-1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Margaret A. Robillard Female
Date of Death Age If Veteran of U.S. Armed Forces,
J9/28/2012 63 years War or Dates
F- Place of Death Hospital, Institution or
ii City, Town or Village Malta Street Address Cedarwood Drive
Manner of Dear❑ Natural Cause ❑Accident El Homicide ❑Suicide ❑ Undetermined ❑Pending
it Circumstances Investigation
W Medical Certifier Name Title
d Alan E. Rauch M D
Address
1003 Louden Road, Latham, N Y 12110
Death Certificate Filed District Number Register Number
City, Town or Village Town Of Malta 0 18
El Burial Date Cemetery or Crematory
10/01/2012 Pine View Crematory
❑Entombment Address
remation Queensbury, New York 12804
Date Place Removed
❑Removal and/or Held
., and/or Address
H Hold
l
O Date Point of
05 ❑Transportation Shipment
L by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
I> Name of Funeral HorrM B Kilmer Funeral Home 01078
Address
126 Main Street, South Glens Falls, Ny
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
;; Address
i
llt
C Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issuedl0/01/2012 Registrar of Vital Statistics -�/A g ._5::1,,,c_4.e..,j-c7
(signature)
District NumkrfJ"�j Place Town Of Malta
i- I certify that the remains
of the decedent identified above were disposed of in accordance with this permit on:
2
iii Date of Disposition 1012112 Place of Disposition •gzvuuCol-cf./mi.—
(address)
Ui
CA
fr (section) (lot number( (grave number)
,J*
Name of Sexton or Pe on in Charge of remises ,Z ',L,- `'{""�
(please print)
iiiSignature Title � i�
(over)
DOH-1555 (02/2004)