Seeley, Kathleen Martha IW
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permi
Bureau of Vital Records
Name First Middle Last Sex
Kathleen Martha Seeley Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/04/2022 83 Years War or Dates
, Place of Death Hospital,Institution or
ZI City,Town or Village Fort Edward Town Street Address 296 Broadway, Fort Edward Town,New York 12828
• Manner of Death []Natural Cause []Accident El Suicide []Undetermined ❑Pending
W I 1 ,Circumstances Investigation
WG Medical Certifier Name Title
Aqeel Gillani MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 45
[]Burial Date Cemetery,Crematory or Facility Name
06/06/2022 Pine View Crematory
Address
EICremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
Hold Address
0
d Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
[]Disinterment
Date Cemetery Address
[]Reinterment
Date Cemetery Address
Permit Issued to Registration Number
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
1— Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/06/2022 Registrar of Vital Statistics Aimee G Makoney(EEectronica/Cy Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �jQ.,.�L. 1'
W Date of Disposition (�—g—ZZ Place of Disposition �,,,�,
2 (address)
W
CC N (section) (lot number) (grave number)
Sv IAA et
O Name of Sexton or Person in Charge of Premises !�(�
Z / ase print
W Signature Title re•-MfriVIC
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on _ , 20
fA
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#