Gilman, Nancy 9 t7
NEW YORK STATE','sEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nancy Lee Gilman Female
'`�, Date of Death Age If Veteran of U.S. Armed Forces,
December 23, 2015 64 War or Dates
' :1 Place of Death
Hospital, Institution or
City, Town or Village Glens Falls
iStreet Address 43 Ridge Street Apt. 406
Manner of Death ❑X Natural Cause ❑Accident n Homicide ❑Suicide 1-7 Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
James North MD
Address
100 Broad Street,Glens Falls,NY 12801
Death Certificate Filed District Number �/ Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
December 24, 2015 Pine View Crematorium
❑Entombment Address
IN Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z 1-1 Removal and/or Held
• and/or Address
F' Hold
Cl)
O Date Point of
NElTransportation Shipment
a. by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
"1,;:?, Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
'I Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
5, Permission is hereby ranted to dispose of the human remains described ab ve i dicated.
s; Date Issued /2-2Y 20/ Registrar of Vital Statistics � � ,%
(signature)
,rs, District Number j j>d/ Place 67 At A, N4J ,dn-Z—
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z DispositionPlace of Disposition P, if W Date of i 2-2 -r� PIA e v,�,,J L.r�..,r.�.�®''
2 (address)
w
N
O (section) ` /(lot number) (grave number)
G
O Name of Sexton or Person in Charge of Premises J I. 1;�n C.�c-M-e-(. -L
Z (please print)
W Signature Title 6farr ,Je/'
(over)
DOH-1555(02/2004)