Cartier, Marie VS 4 COMMONWEALTH OF KENTUCKY
(Rev.9/98) Department for Public Health
Please Press Hard Registrar of Vital Statistics See back of form for instructions
Making Three Copies PROVISIONAL REPORT OF DEATH
(A) Mali
i A.M.
Name t al i e, Cos+-1 Date of Death rA 1 t(i 15 Hour q k1 O 0
Nelson Son Ot
Age c J Race Sex F
County of Death County of Residence
Facility or location of Death W)(Aso( CiArriens NOES r 2 Viorn , ) '3C dskOU3(\ y
MM Include QV/State)
Medical Certifier of Certificate: _ /t l A a U c t_ a RD to
Address
Facility Notes:
Blood and Body Fluid Precautions Advised? YES NO i/ Blood and body fluid precautions should be
observed for any post-mortem procedure regardless of diagnosis.
KENTUCKY ORGAN DONOR AFFILIATES(KODA)- (800)525-3456
In accordance with HCFA's Conditions of Participation-Section 482.110, all deaths must be referred to KODA,
prior to the approach of family, regarding the suitability for organ and/or tissue donation.
la�^lc,l�!115
Date/Time KODA Contacted: 10 UU PrYI Name of KODA Coordinator: tUSA1 I n ^. u
Ruled Out For Donation By KODA: YES NO Family Approached about Donation: YE�S✓J NOiL
If family approached, was consent given for donation: YES NO
Name and Relationship of Family Member Approached:
(B) Authorization is hereby granted to Win dsOY C ardeti:s CCl2c
Facility Name
to release the remains of the above named to } OUG,111►c1 - One•Cal \AOcr t
Funeral Home
for the purpose of transportation and/or disposition.
A Signature Next of Kin
t�\�i�
Signature of L cal Registrar,Deputy Registrar,Coroner or Hospice Nurse Witness T(C) I, representing 4 o'3"L' CIL e e) to L t- F. t
hereby accept the remains of the above named and agree to secure and file a complete and satisfactory certificate
of death wit,in,tjtne limits est blishe KRS 213.
J MTV Alcw SAeptiestdsta` I)e PoIoc4
Signature Address
AQJs7o��b yooe,
'City/State
(D) I am aware of the circumstances surrounding the death of the above named person and hereby authorize cremation
of the remains.
Coroner of County Date
(E) Remains of the above named were buried 1 2/2 3/1 5 cremated
consigned to Pine View Cemetery, Queensbury, NY on •
Name of Cemetery/Crematory
21 Quaker Road, Queensbury, NY 12R04
Address /� Sy....64"-V9^(
CLIZA
Sig e(Sexton or Person in Charge) / t
WHITE COPY-Must accompany deceased YELLOW COPY-Health Department in the County of Death PINK COPY-Facility Copy