VanTassell, Norma NEW YORK STATE DEPARTMENT OF HEALTH 1 l
Vital Records Section y Burial - Transit Permit
Name First Middle Last Sex
Norma L. Van Tassell Female
Date of Death Age ' If Veteran of U.S. Armed Forces,
May 8, 2016 92 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
t Medical Certifier Name Title
Eileen Spinelli,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward
I
-0 Burial Date Cemetery or Crematory
❑Entombment Pine View Crematory
Address
b ,®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
'} Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
A
-= Permission is hereby granted to dispose of the humane ' s describ d b e as dicated.
Date Issued51 0 lbRegistrar of Vital Statistics ,GULL f '
� _�(} signaturec )
District Number 5rI5 Place - E �
,_
7,---, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 61P°k, Place of Disposition Quaker Road Queensbury,NY 12804
TT
(address)
(section) AIL'
(lot(number) (grave number)
Name of Sexton or Person in Charge of PremisesJQ
`/ (please pant)
ilr Signature Title `ye.
(over)
DOH-1555 (02/2004)