Manchester, Pauline Louise NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Pauline Louise Manchester Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/25/2023 100 Years War or Dates
F., Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
W
p Manner of Death ❑X Natural Cause Accident pi HomicideSuicide Undetermined Pending
Circumstances Investigation
0
Medical Certifier Name Title
G Philip Gara MD
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 9
RBurial Date Cemetery,Crematory or Facility Name
01/27/2023 Pine View Crematory
Entombment Address
iiiCremation Queensbury Town,New York
Donation
O❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
CO
0
d Date Point of
N f Transportation
G by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
❑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
_ Remains are Shipped,If Other than Above
N Address
CC
LU
M. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/26/2023 Registrar of Vital Statistics Aimee LMa/ioney(!ElctronicallySgned)
(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:
I-
Z Date of Disposition /23-2oz3 Place of Disposition --? A> e (1 tr 8 kJ 0 bi;ile, p
LU
2 (address)
LU
O A(section)_ �� � ` (lot numper) (grave number)
a Name of Sexton or Person in Charge o remi e Oti
Z (please print)
UJ Signature Title Q IQ,1.T^ili
DOH-1555(07/18)p 1 of 2 ll
.,•a 016638
Public Health Law Sec. 4145(2b)
Receipt
1
1
1 Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# er'!