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Himes, Theresa Ann -t zg NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Theresa Ann Nimes Female Date of Death Age If Veteran of U.S.Armed Forces, 03/17/2021 61 Years War or Dates F— Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 20 Hudson View Lane,Queensbury Town,New York 12804 IJJ p Manner of Death Natural Cause El Accident Homicide ID Suicide El Undetermined ©Pending W Circumstances Investigation W Medical Certifier Name Title 0 Timothy Murphy Coroner Address 52 Haviland Avenue,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 72 Burial Date Cemetery,Crematory or Facility Name 03/19/2021 Pine View Crematory ElEntombment Address ElCremation Queensbury Town,New York ElDonation Q Removal Date Place Removed and/or and/or Held NHold Address O a Date Point of t/) 11 Transportation Shipment ES by Common Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above ' Address LC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/19/2021 Registrar of Vital Statistics CaroC'ne JfiCdegarde Bar6er(ECectronicalty Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 3I IS I l i Place of Disposition jo—.. 2 (a dress) W L (section) (lot nu r) (grave number) 0 Name of Sexton or Person in Charge of P emises �J (please print) LU Signature Title ``Vrf` tv'Z DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 14 64 Receipt Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burl. Official Funeral Directors Reg.or License#