Knowlton, Teena Marie 1t Lj
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Teena Marie Knowlton Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/15/2023 65 Years War or Dates 1981-1982
p.., Place of Death Hospital,Institution or
WCity,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
0 Manner of Death ❑^ Natural Cause {]Accident ❑Homicide {]Suicide {]Undetermined ❑Pending
W ' 'Circumstances Investigation
U
W Medical Certifier Name Title
0 Pauline Heckler NP
Address
4573 State Route 40,Argyle Town,New York 12809
Death Certificate Filed Town Of Argyle District Number Register Number
City,Town or Village 5750 33
Burial Date Cemetery,Crematory or Facility Name
06/16/2023 Pine View Crematory
{]Entombment Address
{]Cremation Queensbury Town, New York
Donation
ZElRemoval Date Place Removed
and/or and/or Held
H Hold Address
N
0
a Date Point of
(I){]Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
{]Disinterment
Date Cemetery Address
IT Reinterment
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
H Remains are Shipped,If Other than Above
.- Address
CC
LU
CI-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/16/2023 Registrar of Vital Statistics S/lelley.Ylckernon(6lectrorricallySigned)
(signature)
District Number 5750 Place Town Of Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— J
Z Date of Disposition ‘Ill(Z3 Place of Disposition 'w� /f--,
W
2 (address)
W
CC N (section) num rr) (grave number)
0 Name of Sexton or Person in Charge of P remises
/ (lot
er
Z please print/
lJU Signature Z
Title l�'%G/i1'l wria2
DOH-1555(07/18)p 1 of 2
1
_ L
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ' delivered on , 20
#�_
Pine View Cemetery Representing the funeral home named on bu5ialperpnit
•fficial Funeral Directors Reg.or License# J