Goldsmith, Nora NEW YORK STATE DEPARTMENT OF HEALTH /;, 3 f `
Vital Records Section Burial - Transit Permit
ir
Name First Middle Last Sex
Nora Elizabeth Goldsmith Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 11, 2012 91 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 ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
a. Circumstances Investigation
, Medical Certifier Name Title
0 Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
Death Certificate Filed District Nu 5 Regist r Number
City, Town or Village Fort Edward 'j )�
❑Burial Date Cemetery or Crematory
July 12, 2012 Pine View Crematory
❑Entombment Address
4 e®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
u ❑ Disinterment Date Cemetery Address
r;.❑ Reinterment Date Cemetery Address
s' Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 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
Address
Permission is h eby anted to dispose of the hum ains descri boy s indicated.
Date Issued?ic).- /� Registrar of Vital Stati ics
_ —� (signatu
District Number ) Place l2,41,-) T �Sa� 10' D
3 9
„.:
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
x Date of Disposition 07/12/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) r. (grave number)
r. Name of Sexton or Person in Char of Premises , hfist16r 114
i
(please print)
Signature L Title arMAPC
3%
(over)
DOH-1555 (02/2004)