Mooso, Alberta NEW YORK STATE DEPARTMENT OF HEALTH ..' It Z-3t
Vital Records Section L Burial - Transit Permit
Name First Middle Last Sex
r Alberta LaBarge Ioso Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 3, 2012 93 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
4-7 Circumstances Investigation
Medical Certifier Name Title
Nawed A. Siddiqui, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed Distr t Number Registe !N nber
City, Town or Village Fort Edward 7 C�
❑Burial Date Cemetery or Crematory
May 4, 2012 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
I❑ Removal and/or Held
and/or Address
Hold
Date Point of
- •. ❑Transportation Shipment
by Common Destination
Carrier
4„ 0Disinterment Date Cemetery Address
P Date CemeteryAddress
ElRenterment
;''''74 Permit Issued to Registration Number
k Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
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 re granted to dispose of the huma 'ns describe ove a indicated.
1,4
Registrar of Vital Statisti
Date Issu 9 %��� z_ZA1 ""` '.Urn
rzi (signatu
rp
District Numbe Place - i�4c-N
i= I certify that the remains of the decedent identified ove were disposed of in accordance with this permit on:
a#N Date of Disposition 05/04/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Premises
-' Name of Sexton or Person in Charge 1r'O , trwcti
�f p
` . Signature Title Z
Y lease print)
(over)
DOH-1555 (02/2004)