Gannon, Thelma NEW YORK STATE DEPARTMENT OF HEALTH'' 1 3$7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Thelma Gannon Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/23/2015 85 years War or Dates
1- of Death Hospital, Institution or
.City (*.0 Q WOW Glens Falls Street Address Park St Glens Falls, N Y 12801
ct Danner of Death 0 Natural Cause 0 Accident ❑Homicide 0 Suicide �Undetermined �Pending
W Circumstances Investigation
w Medical Certifier Name Title
Q Kenneth France M D
Address
Glens Falls Hospital Glens Falls, N Y
Death Certificate Filed District Number Register Number
o%X%Y itr fiX Glens Falls 5601 - 264
r ■Burial Date Cemetery or Crematory
•
05/27/2015 .Pine View Crematory
❑Entombment Address
'Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
f
Hold
Date Point of
Sly.$ Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
•
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer:Funeral Home 01079
Address
82 Broadway Fort Edward, N Y 12828
iiIii Name of Funeral Firm Making Disposition or to Whom
. } Remains are Shipped, If Other than Above
2 Address •
c •
t
Permission is hereby granted to dispose of the human remains described above as indicated.
Oi Date Issued 05/27/2015 Registrar of Vital Statistics IA) C .2_,VJ
(signs ure)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
100',al Date of Disposition 5 f tell'6 Place of Disposition +►.vii C,,-*
(address)
Ili
ta
Cr (section) �-lot number) (grave number)
Name of Sexton or Person in Charge of Premises �"' 1+
.z // (pie�se print)
l Signature 4 Title MCIMATOL
(over)
DOH-1555 (02/2004)