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Tellier, Nancy Jean NEW YORKSTATE DEPARTMENT OF HEALTH Burial- Transit Permit Bureau of Vital Records Name First Middle Last Sex Nancy Jean Tellier I Female Date of Death Age If Veteran of U.S.Armed Forces, 04/24/2020 79 Years War or Dates F Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre p Mannerof Death ©Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation ll) Medical Certifier Name Title Wendy Steinhacker PA Address 152 Sherman Ave,Queensbury Town,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 81 ©Burial Date Cemetery,Crematory or Facility Name 04/29/2020 Pine View Cemetery Entombment Address ❑Cremation Queensbury Town,New York Donation ORemoval Date Place Removed and/or and/or Held H Hold Address O (L Date Point of to Transportation Shipment Q by Common Carrier Destination ❑Disinterment ry Date Cemete 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 F Remains are Shipped,If Otherthan Above 2 Address cc W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/28/2020 Registrar of Vital Statistics Caroline Mi(Cegarde Barber(ECectronicaffy Signed) (signature/ District Number 5657 Place Queensbury, 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 5/8/2020 Place of Disposition Pine View 21 Quaker Rd. Queensbury,NY 12304 W (address/ W ERIE 83 E 1 N (section/ (lot number) (grave number) M Name of Sexton or erson in Charge of Pr mises Connie Goeder Z (p/ea print/ W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 010386 Receipt Human remains of delivered on , 20 Pine View Cernet6f Representing the funeral home name4 ou,burial permit Official Funeral Directors Reg.or License# '! � TELLIER NAME Nancy Jean Tellier Age: 79 Lot Owner: Andrew Tellier Lot# Erie 83E Grave# Case: Concrete Died: 4/2 4/2 0 2 0 Interred:5/8/2 0 2 0 Funeral Home: Carleton FH Cemetery: pine View