Chartier, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH4»;. * 4/ If'Z(. .
Vital Records Section 4 Burial - ransit Permit
i! ` $s
Name First Middle 1 Last Sex
Dorothy Chartier Female
Date of Death Age If /eteran of U.S. Armed Forces,
August 29, 2016 97 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Eileen Spinelli,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register N
City, Town or Village Fort Edward
5�rjFj .er
❑Burial Date Cemetery or'Crematory
September 2, 2016 Pine View Crematory
❑Entombment Address
..�-®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
0 and/or Address
E Hold
CA Date Point of
to ❑Transportation Shipment
0 by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
- Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
y Name of Funeral Firm Making Disposition or to Whom
b' Remains are Shipped, If Other than Above
ZAddress
d" Permission is hoe/c9.
by granted to dispose of the human re 4 describe ove as ind'cated.
' Date Issued / J1 Registrar of Vital Statistics w��
District Number � �5� PlaceZt)/(0
( J2S letliS V l it ature)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IDate of Disposition 09/02/2016 Place of Disposition Quaker Road Queensbury,NY 12804
; (address)
6
ft (section) A14914-•(lot number) (grave number)
ci Name of Sexton or Person in Charg of Premises �"'�
(please print)
it 0411(1.
W Signature Title
T
(over)
DOH-1555 (02/2004)