Parker, Mary ti SS"
NEW YORK STATE DEPARTMENT OF HEALTH *
Vital Records Section 4 ' ' Burial - Transit Permit
T Name First Middle Last Sex
Mary E. Parker Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 10, 2012 70 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
' Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined IT❑ Pending
si Circumstances Investigation
• Medical Certifier Name Title
Paul F. Bachman, ME
Address
Warrensburg, NY 12885
' Death Certificate Filed District Numl �� '.\ RegistetNuumber
3
City, Town or Village Glens Falls
z.. • Date
g- ❑Burial Cemetery or Crematory
, December 11, 2012 Pine View Crematory
❑Entombment Address
w -'®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
a. ❑Transportation Shipment
tk by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
., 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 hereby ranted to dispose of the human remains describ.id,AbTye j' in r, t4d.
Date Issued %2��/�/2— Registrar of Vital Statistics !cam d�
(signature)
District Number .j 60/ Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/11/2012 Place of Disposition Quaker Road Queensbury,NY 12804 11.)e-vi
(address)
(section) J (lot-number) (grave number)
Name of Sexton or Person in Char a of Premises G h<<,
( ease punt)
Signature / l / Title C (�1l-rtki
(over)
DOH-1555(02/2004)