Christoff, Thelma Orelia Lynette NEW YORK STATE DEPARTMENTri..F,/ /►OFHEALTH � � V
Bureau of Vital Records Burial - Transit Pe mit
Name First Middle
Last j Sex
Thelma Orelia Lynette Christoff
Date of Death Female
Age If Veteran of U.S.Armed Forces,
06/11/2022 38 Years
War or Dates
F. Place of Death Hospital,Institution or
Z CityILI ,Town or Village Glens Falls
Street Address Glens Falls Hospital
a Manner of Death LLI Natural Cause ❑Accident
Homicide Suicide ❑Undetermined ❑Pending
0W Medical Certifier Circumstances Investigation
Name Title
Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number
City,Town or Village 5601 Register Number
320
Burial Date Cemetery,Crematory or Facility Name
06/16/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Date Place Removed
D�Removal
p and/or and/or Held
Hold Address
Transportation Date Point of
ES 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
i—. Remains are Shipped,If Other than Above
a Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/15/2022 Registrar of Vital Statistics Megan No fin(E(ectronically Signed)
/signature/
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition (it 111 i Place of Disposition r� «Z.
2address)
W
N
CC
(section) rot number) SA%
/grave number/
2 Name of Sexton or Person in Charge of Pr ises a1 ' Sii
Z " (p/ease int)
7
W Si nature ` t� Title G 'M itiqe
g
DOH-1555107h8)p 1 of 2
Public Health Law Sec. 4145(2b)
IReceipt
1
1 1
1 Human remains of delivered on • , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#