Paris, Nancy NEW YORK STATE DEPARTMENT OF HEALTH'S 1 4 Z:1 5-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nancy Kay Paris Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 8, 2016 77 War or Dates
Place of Death Hospital, Institution or
in City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
tiLif Circumstances Investigation
Medical Certifier Name Title
Michael Fuller, Dr.
Address
East Street Fort Edward, NY 12828
Death Certificate Filed District Number ' �/ Register Nufn rr
City, Town or Village Glens Falls ��
❑Burial Date Cemetery or Crematory
April 11, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z nl❑ Removal and/or Held
0 and/or Address
Hold
(' Date Point of
❑Transportation Shipment
by Common Destination
0 Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he eb granted to dispose of the humaniemain escribe above as i dic ted.
Date Issued Registr f Vital Statistics Q( �\��i L
--, ( ' natu )
District Number 5bj / Place -Q, /C�- i
f
I certify that the remains of the decedent identified above were disposed of in accordant with this permit on:
Date of Disposition 04/11/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
re
(section) ` (lot numb
(grave number)
Name of Sexton or Person in Charge of Premises u^ L J1
I (please print)
Signature Ti it
9 tle
(over)
DOH-1555 (02/2004)