Westerman, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name F tvid Middle Last Sex
Westerman Ma e
Date 8f/4Vt 97 Age 78 If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Glens Falls Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death ®Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical C&arv�ieJ L. Foo e, MD Title
A. 9&slain St. Hudson Falls NY 12839
Death Ce ----T
rtificate Filed Glens Falls District Number ram/ Register Number
City, Town or Village J 6o ( 13
Date Cemetery or Crematory
Burial 3/15/1997 Pine View Crematory
❑Cremation A uaxer Rd, Queensbury, Ny 12804
Date Place Removed
z❑Removal and/or Held
�•• and/or Address
Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomeM.E. Kilmer Funeral Home 01057
[ Address
136 Main St. , South Glens Falls, NY 1280
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 de c/ribe l abo as 1 hatad.
Date Issued 3 /3 q Registrar of Vital Statistics
(signature)
District Number Place �-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition J Place of Disposition itN� �� 0,�• M/g�4/�I
(address)
Lp
>l (section) (lot nu ber) (grave number)
0 Name of Sexton r Person Charge of Pr( ises
(please print)
Signature Title 3� !
DOH-1555 (10/89) p. 1 of 2 VS-61
R