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Newcomb, Thelma Ethel . f # pg NEW YORKSTATE DEPARTMENT OF HEALTH k° Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thelma Ethel Newcomb Female Date of Death Age If Veteran of U.S.Armed Forces, 03/08/2020 87 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc p Manner of Death © Natural Cause Accident Homicide Suicide Undetermined ❑Pending W Circumstances Investigation WMedical Certifier Name Title John Quaresima MD Address 319 Broadway, Fort Edward Town, New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 19 Burial Date Cemetery,Crematory or Facility Name 03/09/2020 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York Donation Z Date Place Removed �Removal and/or and/or Held H Hold Address as O d Date Point of (A ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Registration Number Permit Issued to 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 W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/09/2020 Registrar of Vital Statistics Aimee Mahoney(Electronically Signed) (signature) District Number 5755 Place Fort Edward, New York 1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition � 1Q �� Place of Disposition 6 � r'"' -r (address) 2 W /section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises J� 1 u ' (p ease print) W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0.1 3 4 0 4 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#