Nicodemo, Susan NEW YORK STATE DEPARTMENT OF HEALTH it )73
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susan Mary Nicodemo Female
Date of Death Age If Veteran of U.S. Armed Forces,
0 . December 10, 2014 101 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
?• Manner of Death rn
iLxi Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ® Pending
4` Circumstances Investigation
Medical Certifier Name Title
William Papura, Dr.
Address
1134 Rt 29 Greenwich, NY 12834
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 41 .� /
El Burial Date Cemetery or Crematory
December 15, 2014 Pine View Crematory
gt 0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
a Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
ElTransportation Shipment
by Common Destination
il Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
F. 123 Main St., Ar le NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human r ains described a ove as in• -d.
,45
Date Issued /.2. lv Registrar of Vital Statistics /2-,'-e .
(signature)
'�- District Number 5 1/ Place 6/e4s///4
§yew
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/15/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
_' (section) /f , (lot number) (grave number)
4s Name of Sexton or Person " Charg f Premises (tr•s' I.— St,
(please print)
� u Signature Title
eizi +4,11,f
(over)
DOH-1555 (02/2004)