Haley, Antoinette Catherine NEW YORK STATE DEPARTMENT OF H EALTH
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Antoinette Catherine Haley Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/21/2021 79 Years War or Dates
l^ Place of Death Hospital,Institution or
Z City,Town or Village Argyle Village Street Address 552 West Street,Argyle Village, New York 12809
W Manner of Death Undetermined Pending
� � Natural Cause �Accident �Homicide Suicide
W Circumstances Investigation
U
W Medical Certifier Name Title
O Glen Anderson PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Argyle 5750 29
Burial Date Cemetery,Crematory or Facility Name
04/23/2021 Plne View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
ZO ElRemoval and/or Date Place Removed
and/or Held
H Hold Address
0
d Date Point of
Cl) ❑Transportation Shipment
p by Common
Carrier Destination
❑ Disinterment
Date Cemetery Address
Re interment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/22/2021 Registrar of Vital Statistics ShelleyAlclernvn gkctronicall:y Signer
(signature)
District Number 5750 Place Argyle, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lL.
Z Date of Disposition ��123'�Zf Place of Disposition i+r `--
2 (address)
W
CC CC (section) allot number) (grave number)
Name of Sexton or Person in Charge of Premises r lM1At
/p(ease�rint)
[�/ �L—� Title `� 2
W Signature f e1s` W
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# i