Knox, Helen s
t1 ,3
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
A Name First Middle Last Sex
Female
'zi,F-4 Date of Death Age If Veteran of U.S. Armed Forces,
mi 06/17/2018 91 Years War or Dates
!_i,.--, Place of Death Hospital, Institution or
-11.1 City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
IFJ•t: Manner of Death ri Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined ri Pending
ril
X Circumstances 'Investigation
rri Medical Certifier Name Title
Thomas Kandora MD
Address
PA
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 27
❑Burial Date Cemetery or Crematory
06/18/2018 Pine View Crematory
❑Entombmentpt . Address
®Cremation Queensbury Town, New York
01
Date Place Removed
❑Removal and/or Held
Ili and/or Address
Hold
ai
Date Point of
❑Transportation Shipment
by Common Destination
Carrier _
❑Disinterment
Date Cemetery Address
Renterment Date Cemetery Address
:4 LiPermit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
soil
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
N. Date Issued 06/18/2018 Registrar of Vital Statistics Aimee Mahoney(ECectronicaCCySigned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition lP) Zolig Place of Disposition Dj,J r�r t
(address)
trill
+ (section) //(lot number) (grave number)
Name of Sexton or Person in Charge o Premises G4n ..41-
(p/ se printl
tI Signature & Title till BYl 1 +/
(over)
DOH-1555 (02/2004)