Normandin, Rita NEW YORK STATE DEPARTMENT OF HEALTH 1 it 5°1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rita M. Normandin Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 21, 2015 74 War or Dates
- Place of Death Hospital, Institution or
City, Town or Village South Glens Falls Street Address 40 Chestnut Street
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Robert L. Evans, Dr.
Address
Three Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City Town or Village South Glens Falls
TA❑Burial Date Cemetery or Crematory
April 23, 2015 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
'❑Transportation Shipment
„ _' by Common Destination
Carrier
tt`� 1-1 Date Cemetery Address
s ❑ Disinterment
Date Cemetery Address
❑ Reinterment
w 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
I Address
Permission is hereby granted to dispose of the human re �escribed a as pdicate .,
Date Issued 41.;`31\S Registrar of Vital Statistics � [
(signature)
Ai District Number St q Place �v/`//7 C /01,5 f.S aZia
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/23/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numbe) (grave number)
tea` Name of Sexton or Person in Charge of Premises a,
. lease print)
? Signature / _ Title <ttEZoltlS✓Z-
(over)
DOH-1555 (02/2004)