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Keith, Nancy Mary
/°� NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Nancy Mary Keith Female Date of Death Age If Veteran of U.S.Armed Forces, 01/28/2020 79 Years War or Dates H. Place of Death Hospital,Institution or Z City,Town or Village Hudson Falls Village Street Address 11 Jones Avenue, Hudson Falls Village,New York 12839 WW Mannerof Death © Natural.Cause Accident Homicide Suicide Undetermined Pending C.) Circumstances Investigation W Medical Certifier Name Title Rita All NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Hudson Falls Village 5726 2 Burial Date Cemetery,Crematory or Facility Name 01/30/2020 Pine View Crematorium Entombment Address ICremation Queensbury Town,New York Donation OZ Removal Date Place Removed and/or and/or Held H N Hold Address O a Date Point of W Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67, Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition orto Whom 1�- Remains are Shipped,If Other than Above Address W (L Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/30/2020 Registrar of Vital Statistics Cynthia_A Bardin(ECectronicalTy Signed) (signature) District Number 5726 Place Hudson Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 1131176 Place of Disposition W 2 (address) W N (sedion) (lot number) (grave number) IX C Name of Sexton or Person in Charge of Premises Z (p e print/ W Signature (r.� Title ' DOH-1555(o7/18)p 1 of 2 i Public Health Law Sec. 4145(2b) 013299 ti Receipt Human remains of J delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#