O'Connor, Gloria NEW YORK STATE DEPARTMENT OF HEALTH-- `' -- /g
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gloria Elizabeth O'Connor Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 30, 2016 86 War or Dates
Place of Death Hospital, Institution or
;; City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death Frixj Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Eileen Spinelli,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed Distric 2„ i b_ ' Register tuber
City, Town or Village Fort Edward LD
❑Burial Date Cemetery or Crematory
February 2, 2016 Pine View Crematory
❑Entombment Address
' '®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
illiTransportation Shipment
by Common Destination
Carrier
Date Cemetery Address
III Disinterment
❑ 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
Permission is her y ranted to dispose of the human - - s described a ve as ' dicated.
Date Issue � Registrar of Vital Statisti•
.---------- (signature) _� �
District Numbe 5 75 Place C
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/02/2016 Place of Disposition Quaker Road Queensbury,NY 12804 f;At,y C,y,, Cfcm +'y
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises `I cr,�+t'y ��r S
(please print)
Signature 4"' Title GfC' `1405
T
(over)
DOH-1555 (02/2004)