Nassivera, Gladys NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
s Nassivera
Date of Death Age If Veteran of U.S. Armed Forces,
88 War or Dates
Place of Bath Hospital, Institution or
City, Town or Village Argyle Street AddressPleasant Valley Infirmary
Manner of Death Q Natural Cause Accident Homicide Suicide ❑Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
MD Philip Gara MD
Address
318 Broadway, Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
[ City, Town or Village p.r le `7 O
7Date Cemetery or Crematory
0 Burial1qqq Pine View Crematory
Address
Cremation
4ker Road Oueensbury, NY 12804
Date Place Removed
0❑Removal and/or Held
P and/or Address
Hold
Q Date Point of
y Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01057
Address
t Edward NY 12828
-Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
>` Permission is ereby granted to dispose of the human r ains descr' ed above as indicated.
Date Issued 6� 9 Registrar of Vital Statistics
(signature)
District Number Place Argyle,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W. T/� , I
Date of.Disposition Place of Disposition �/ lvk /�/f j(!�]
(address)
N
fl� (section) n t n m er) (grave number)
0 Name of Sexton or Person in Charge of Premises "C-b fM/0 /1-41* P/�GtJ
g (please print) _
Signature Zx—�—� Title
DOH<t555 (10/89) p: 1 of 2 VS-61