Graham, Nancy NEW YORK STATE DEPARTMENT OF HEALTH # 2
Vital Records Section Burial - Transit rmit
Name First Middle Last Sex
Nancy Ellen Graham Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/13/2013 89 years War or Dates
# - a oTT Death Hospital, Institution or
City Towihi -;- Street Address
fit ♦..��..XX Glens Falls park st I s falls, n y 12801
er o ea h Natural Cause Accident Homicide E Suicide undetermined Pending
tiliCircumstances Investigation
ill Medical Certifier Name Title
Add Suzannc Blood M. D.
ress
•
14 Manor Drive Queensbury, N Y 12804
Death Certificate Filed District Number Register Number
ity T0W fr l XX Glens Falls 5601 211
LJBurial ''abate Cemetery or Crematory
0 Entombment 05/14/2013 Ping View Cemetgry
Address
iii Cremation • f,;,-e"..bury, NY 1')Q<0r1
Date Place Removed
❑
Removal and/or Held
and/or
Address
it
0
Hold
0 Date Point of
❑Transportation Shipment
O by Common Destination
Carrier
"'`'Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Mi Address
11 I afayette Street (Jueensbury, N Y 12804
iiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tr
In
Permission is hereby granted to dispose of the human remains described above as,indicated.
Mi Date Issued 05/13/2013 Registrar of Vital Statistics t/d6t_ _V (A)
(signature)
District Number Place �g �����
5601 Glens Falls
;:.s>;_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111• Date of Disposition 3lltilb Place of Disposition -0.4L h.4,,) C pta s
(address)
in
to
lz (section) (lot number (grave number)
S
• Name of Sexton or Person - Charge of Prem. es Ai "%
2 } (please print)
Signature 4.� Title «ilftrd�
•
(over)
•
DOH-1555 (02/2004)