Killmeier,Donna Marie 130
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records ^41 "' Burial - Transit Permit
Name First Middle Last Sex
Donna Marie Killmeier Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/12/2020 82 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
IU
0 Manner of Death ❑n Natural Cause ElAccident 1=1 Homicide ❑Suicide El Undetermined 0 Pending
ILI
0 Circumstances Investigation
IU Medical Certifier Name Title
Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 575
❑Burial Date Cemetery,Crematory or Facility Name
12/15/2020 Pine View Crematory
- 0 Entombment Address
1 Cremation Queensbury Town,New York
❑Donation
Z El Removal Date Place Removed
and/or and/or Held
F Hold Address
)
0
CL 1-1 Date Point of
N ❑Transportation
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F... Remains are Shipped,If Other than Above
- Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/15/2020 Registrar of Vital Statistics $',o6ertf7nefrew Curtis g1ectronicalySrgned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— ' If /?
Z Date of Disposition 12/i (to Place of Disposition �1,,.IL C f4-'8c`
LLI
2 (address)
W
CC N (section) rht,(Itot number+�^4ft (grave number)
6
40 Name of Sexton or Person in Charge of Premises
Z
(pie se print)
IIISignature Title 11747419, ,
DOH-1555(07/t8)p 1 of 2
� t'
Public Health Law Sec. 4145(2b) � 1 1 4 2q
Receipt
Human remains of ' delivered on ` , 20.
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# .`