Nassivera, Cora 10
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
�; Cora Mary Nassivera Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 23, 2013 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls , Street Address Glens Falls Hospital
Manner of Death J Natural Cause 0 Accident El Homicide El Suicide DUndetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 6 0 \ '' 1
D Burial Date Cemetery or Crematory
February 28, 2013 Pine View Crematory
❑Entombment Address
4,4x Cremation Queensbury,NY�® Quaker Road Queensbu NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
;0 Carrier
Disinterment Date Cemetery Address
tfi Date Cemetery Address
IQ El Reinterment
1, Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
1. .: Address
82 Broadway, Fort Edward NY 12828
4.4 Name of Funeral Firm Making Disposition or to Whom
s Remains are Shipped, If Other than Above
iFY Address
�fr
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2/2 5 1(3 Registrar of Vital Statistics UN) C& y-.Q W
(signature)
District Number�j f 0l Place , �f l 15,N Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i Date of Disposition 02/28/2013 Place of Disposition Quaker Road Queensbury,NY 12804
.. (address)
,11
(section) 4 (lot number) , (grave number)
,
Name of Sexton or Person in Charge of Premises t%b.,a ili
(please print)
Signature df-- Title CeArtioAKO
(over)
DOH-1555 (02/2004)