Seeholzer, Grace -rov
7 -.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
, Name First Middle Last Sex
Grace Ellen Seeholzer Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/29/2018 91 Years War or Dates
fa, Place of Death Hospital, Institution or
5 City, Town Or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
Manner of Death i Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Ci Suzanne Blood MD
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 65
❑Burial Date Cemetery or Crematory
05/30/2018 Pine View Crematory
y['Entombment Address
a®Cremation Queensbury Town, New York
Date Place Removed
K❑Removal and/or Held
and/or Address
a Hold
0 Date Point of
gi 0 Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
::€ Address
IX
Permission is hereby granted to dispose of the human remains described above as indicated.
. Date Issued 05/29/2018 Registrar of Vital Statistics Caroline.7fBarber(ECectronicalTySigned)
,',a (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:
Imo
ILI Date of Disposition s13i lit Place of Disposition
L �AL (address)
(section) (lo umber) 5 (grave number)
Name of Sexton or Person in Charge of Premises 4+
(please rint)
Signature -4 Title /-.Af pa
(over)
DOH-1555 (02/2004)