Irwin, Jean ilsg
NEW YORK STATE DEPARTMENT OF HEALTH ?,.# .
Vital Records Section Burial - Transit Permit
7 Name First Middle Last Sex
Jean C.Irwin Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/25/2018 92 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death 0 Natural Cause ❑Accident ❑Homicide ElSuicide ElUndetermined ❑Pending
141 Circumstances Investigation_
Medical Certifier Nynrne Title
C. Daniel Larson MD
Address
Si 319 Broadway,Fort Edward Town,New York 12828
- Death Certificate Filed District Number Register Number
� City, Town or Village Fort& ward 5755 58
❑Burial Date Cemetery or Crematory
60. 10/26/2018 Pine View Crematory
❑Entombment Address —
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
• Hold
Date Point of
Transportation Shipment
fl by Common Destination
ri Carrier
,❑Disinterment Date Cemetery Address
i
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
v== Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
Address
riX
Permission is hereby granted to dispose of the human remains described above as indicated.
10
., Date Issued 10/25/2018 Registrar of Vital Statistics Aimee 9Kahoney(E(ectronicatTySigned)
-_ (signature)
i District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I0 (tgt h8 Place of Disposition ft/ 4 '`N.,
(address)
g- (section) (lot number)r i c (grave number)
1 Name of Sexton or Person in Cha4rge of Premiss i i rl l 5 -04
(please print)
Signature Title GVA 3'd.
(over)
DOH-1555 (02/2004)