Mitchell, Nellie NEW YORK STATE DEPARTMENT OF HEALTH v ' P. # 53L
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nellie Mitchell Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 21, 2015 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 2 Allen Lane
Manner of DeathE.i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Carol RPA-C Conolly,
; Address
Irongate Glens Falls, NY 12801
Ceat own ate Vill geed Queensbury District Number Register Number
a ❑Burial Date Cemetery or Crematory
7� July 22, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Y ❑ Removal and/or Held
` and/or Address Hold
Date Point of
' ❑Transportation Shipment
; by Common Destination
'' Carrier
ElDisinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
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
4 Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rerpanys esciibe Indicated.
_ Date Issued "1-;.�--t c Registrar of Vital Statistics c �
(signature)
District Number `j(yS Place ' t u � rJ
I certify that the remains of the decedent identified above w disposed of in ac rdance wit this permit on:
_' Date of Disposition 07/22/2015 Place of Disposition Q r Road Queensbury 12804
(address)
.., (section) (lot number) (grave number)
' 'i Name of Sexton or Person in Charge of Premises d„Iiik soli
(please print)
Signature �� Title (izit 1V(#
(over)
DOH-1555 (02/2004)