MacDonald, Cecelia NEW YORK STATE DEPARTMENT OF HEALTH 4 3”
Vital Records Section • , Burial - Transit Permit
Name First Middle Last Sex
krAt
Cecelia MacDonald Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 7, 2012 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident n Homicide 0 Suicide 0 Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed District Number s- Register Number
Ci Town or Village 3as
❑Burial Date Cemetery or Crematory
July 9, 2012 Pine View Crematory
❑Entombment Address
`i ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
El Removal and/or Held
and/or Address
Hold
Date Point of
- ❑Transportation Shipment
by Common Destination
`= Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' = Permit Issued to Registration Number
' i. 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 hereby granted to dispose of the human remains describe a ovv ind'
iL Registrar of Vil Sttiti taascs fir/ G2y
Date Issued 67�0 /G
/� // (signature)
District Number SAD/ Place lv�/ A6. Ay pied
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/09/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
<° Name of Sexton or Person in Charg of Premises (���� r 5e/w
please print)
Signature Title C MATot
(over)
DOH-1555 (02/2004)