Normandin, Theresa Jane 1-II?
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Theresa Jane Normandin Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/06/2022 81 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 169 Reservoir Road,Moreau Town,New York 12828
Manner of Death
CINatural Cause Accident El Homicide El Suicide El Undetermined El Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
0 Glen Anderson PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 8
Burial Date Cemetery,Crematory or Facility Name
02/08/2022 Pine View Crematory
❑Entombment Address
O Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
~N Hold Address
O
a. Date Point of
Cl) Transportation Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
5' Address
W
tL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/08/2022 Registrar of Vital Statistics Leeann Mc cabe(Electronically Signed)
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition as,�-If .44—, Place of Disposition p;n.L �,-,w � rtft cJ-cKy
2 (address)
W
CC
(section) (lot number) (grave number)
gName of Sexton or Pers in Charge of Premises �-Q,,rmC.Y. S294 CL S
Z (please print)
W Signature Ve-Se`PiP
Title �,fe, 6r
DOH-1555(07/18)p t of 2
., b
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20 f
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#