Nassivera, Bruce 1.
NEW YORK STATE DEPARTMENT OF HEALTH .v Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
�' Bruce Allen Nassivera Male
_ Date of Death Age If Veteran of U.S. Armed Forces,
November 29, 2014 62 War or Dates
Place of Death Hospital, Institution or
={ City, Town or Village Street Address 50 North Street
Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
Max Crossman, M.D. Dr.
Address
65 Poultney Steet Whitehall, NY 12887
Death Certificate Filed District Number Register Number
City, Town or Village 57 _ O
" ,0 Burial Date Cemetery or Crematory
December 3, 2014 Pine View Crematory
„ �0 Entombment Address
<?®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Cemetery Address
0 Reinterment
Permit Issued to
Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079 „,F%`
Address
82 Broadway, Fort Edward NY 12828
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 remai described above as indicated.
Date Issued Dtc.. a 0)OI I Registrar of Vital Statistics - (,jam_
(signature)
District Number 5-7 a(o Place
`; I certify that the remains of the decedent identified abov were disposed of in accordance with this permit on:
Date of Disposition 12/03/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
4.
(section) 1f. (lot number) (grave number)
Name of Sexton or Person in Char a of Premises a`r,se 1-1 r Stow4
(dlease print)
Signature Title / lvitiNkk-,
(over)
DOH-1555(02/2004)