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Nestle, Thelma NEWYORK STATE DEPARTMENT OF HEALTH BUrla� - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thelma Nestle Female Date of Death If Veteran f U.S.Armed Forces, 01/25/2020 :jA'e 8 Years War or Dotes ZPlace of Death Hospital,Institution or W City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing p Manner of Death © Natural Cause ❑Accident Homicide Suicide Undetermined Pending W V Circumstances Investigation Q Medical Certifier Name Title Leonard Gelman MD Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 4 Burial Date Cemetery,Crematory or Facility Name 01/28/2020 Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation 0 Removal Date Place Removed and/or and/or Held N Hold Address O IL Date Point of N Transportation S by Common Shipment Carrier Destination Disinterment Date Cemetery Address In Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom t` Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/28/2020 Registrar of Vital Statistics Jenny Lind-a 914arteffe(ECectronicaffy Signed) (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition I I 3p 170 Place of Disposition (,, � /address/ W U) Q (sedion) (tot number) (grave number) CName of Sexton or Person in Charge of P mises it Z (pi se print) W Signature Title �`� DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) r F Receipt Human remains of delivered on i a �` , 20 Pine View Cemetery Representing the funeral home named pn.burial permit Official Funeral Directors Reg.or License# ft _