West, Nancy P• . '' t i3g
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nancy West Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 1 /2 6/2 01 5 8 5 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address • Fort Hudson Nursing Home
Manner of Death® Natural Cause ❑Accident ❑Homicide ElSuicide El❑Undetermined ri❑Pending
tij Circumstances Investigation
ut Medical Certifier Name Michele Harding for Title
44 Thomas Kandora XRpC
Address
327 Broadway, Fort Edward, NY 12828
Death Certificate Filed District u berr Register Number
iM City, Town or Village Fort edward 5 . ,
❑Burial Date • Cemetery or Crematory
11 /27/2015 Pine View Cremtaory
i< ❑Entombment Address
gi®Cremation Quaker Road, Oueenshury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
}= Hold
lb
0 Date Point of
CL
❑Transportation Shipment .
G by Common Destination
iN Carrier
Disinterment Date Cemetery Address
:M ElReinterment Date Cemetery Address
Permit Issued to Registration Number
>s Name of Funeral Home M.B. Kilmer Funeral HOme 01 079
Address
82 Broadway, Fort Edward, NY 12828
F > Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
;' Address
Z
'Li
9` Permission is hereby granted to dispose of the human re - s described a ove a indicated.
Date Issued 1 1 /2 7/2 01 5 Registrar of Vital Statistics Y 1
(signature)
District Number 6.155 Place aC161-rs± L 4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ILI Date of Disposition a/301I5* Place of Disposition 24V.... ipfti.,..
2 (address) 424
lil
L
CC (section) (lot number) (grave number)
d.
Name of Sexton or Person in Charge f Premises /4r,s Sinn*
2 (pl ase print)
ta 4 <-
Signature Title c '`]
(over)
DOH-1555 (02/2004)