Bussey, Gwendolyn NEW YORK STATE DEPARTMENT OF HEALTH r 1 W
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gwendolyn Y Bussey Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 15, 2014 94 War or Dates
-. Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
rn Medical Certifier Name Title
Bernardo R Villajuan, Dr.
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Numb Reg Register Number
City, Town or Village Fort Edward 755 ' S
v_ ❑Burial Date Cemetery or Crematory
May 16, 2014 Pine View Crematory
❑Entombment Address
®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
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
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 ere y granted to dispose of the human reins describ d ab5'ig
ye s indicated.
Registrar of Vital Statistics 7,( - (}L�.,
Date Issued g �-
-T (signature)
;' District Number 575 Place �j,()-� 0e6 'l; el(AJCLA-.
:.' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
&" Date of Disposition 05/16/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature Title
(over)
DOH-1555 (02/2004)