Vonic, Nancy NEW YORK STATE DEPARTMENT OF HEALTH ,,- t 3 S,
Vital Records Section -t. t Burial - Transit Permit
Name First Middle Last Sex
�� Nancy L. Vonic Female
• Date of Death Age If Veteran of U.S. Armed Forces,
July 2, 2013 74 War or Dates
Place of Death Hospital, Institution or
r City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Aqeel A. Gillani, M.D. Dr.
i Address
_ 102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number F j Register Nurnberg 8,0
City, Town or Village Glens Falls
❑Burial Date Cemetery or Crematory
July 8, 2013 Pine View Crematory
0 Entombment Address
• ®Cremation Quaker Road Queensbury,NY 12804
; Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
w❑Transportation Shipment
by Common Destination
Carrier
• j ❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
riv
• 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
rt .
Permission is hereby granted to dispose of the human remains described above as indicated.
1M'iVi. Date Issued ') x ' ) 1� Registrar of Vital Statistics t/ C'A.ti,Yy,�,Q
(signature
rrJj
District Number So I Place 6 Csz„,-s cc, 1k5, N y
N : I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t, Date of Disposition 07/08/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) A (sot number) f'" (grave number)
Name of Sexton or Perso in Charge of Premises tz,4 (�r J�,ar1►t�'1
(pi se print)
• Signature Title efiErigo(
(over)
DOH-1555 (02/2004)