Thomas, Jean NEW YORK STATE DEPARTMENT OF HEALTH 4 _ v 14 Pc
Vital Records Section Burial - Transit Permit
: Name First Middle Last Sex
Jean N. Thomas Female
r', Date of Death Age If Veteran of U.S. Armed Forces,
December 3, 2012 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Deathrrl
.i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel C. Larson, M.D. Dr.
Address
Broad Street Glen Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward ,-5-75 A�7
Date Cemetery or Crematory
,ram ID Burial December 5, 2012 Pine View Crematory
ktsAr❑Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
* .-
Date Place Removed
4 ❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
t r
❑ Disinterment Date Cemetery Address
trrtr:❑ 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
44 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
=; Permission is her by ranted to dispose of the human r ins describe, boy as indicated.
Date Issue 47 Registrar of Vital Statistic __,
(signatu
District Number 7 Place
irk
?; I certify that the remains of the decedent identifi bove were disposed of in accordance with this permit on:
Date of Disposition 12/05/2012 Place of Disposition Quaker Road Queensbury,NY 12804
! (address)
(section) A (lot number) S (grave number)
it
Name of Sexton or Person in Charge f Premises
�; e p
(plbase print)
Signature Title akitIATO:,
(over)
DOH-1555 (02/2004)