Blais, Suzanne C 913
NEW YORK STATE DEPARTMENT OF H EALTH �---. Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Suzanne C.Blais Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/10/2022 75 Years War or Dates
(— Place of Death Hospital,Institution or
W City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death El Natural Cause Accident 0 Homicide Suicide Undetermined n Pending
W
C.) Circumstances f 'Investigation
W Medical Certifier Name Title
O Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 89
RDateBurial
Cemetery,Crematory or Facility Name
12/12/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
c. Date Point of
U)❑Transportation Shipment
p 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-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
5 Address
CC
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/12/2022 Registrar of Vital Statistics )imee L Maloney(ElectronicaK Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Zi"---,..V-
7 /J
W Date of Disposition I2IIZizi Place of Disposition `41
2 address)
W
NCC (section) number) (grave number)
0 Name of Sexton or Person in Charge remises 4. (lot
�`' (p( se print)
Z
W Signature Title I 700H
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
View Cemetery Representing the funeral home named on burial permit
Funeral Directors Reg.or License# •'