Pratt, Lois NEW YORK STATE DEPARTMENT OF HEALTH
II if 410
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lois I. Pratt Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 27, 2015 79 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death IL.] Natural Cause III Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
gyCircumstances Investigation
Medical Certifier Name Title
Michele Harding,
Address
327 Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register ber
City, Town or Village Fort Edward 51,r, 5t
❑Burial Date Cemetery or Crematory
June 1, 2015 Pine View Crematory
:0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
5 1-1
Removal and/or Held
and/or Address
Hold
Date Point of
'.❑Transportation Shipment
by Common Destination
' Carrier
Y ❑ Disinterment
Date Cemetery Address
IllReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
1 Address
tki 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
=' ` Remains are Shipped, If Other than Above
: Address
Permission is hereby g anted to dispose of the human remai•s d ,ibed above s in ica
Date Issued egistrar of Vital Statistics Q /L
��' 14.41.A.)
� t (si�nare}
District Number 5755 Place I O 1AY7\. O5 1 — NWr�I,J1 COv)Cl
ss,..,,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/01/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
x
- (section) (lot number) (grave number)
'' Name of Sexton or Person in Char e of Premises /,-i
(ple se print)
' Signature Title liiimt 'iC
(over)
DOH-1555 (02/2004)