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Tomb, Constance Jane 3oy NEW YORKSTATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Constance Jane Tomb Female Date of Death Age If Veteran of U.S.Armed Forces, 04/01/2023 76 Years War or Dates 1._ Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc p Manner of Death El Natural Cause Accident I I Homicide nSuicide nUndetermined ❑Pending W ' II U Circumstances Investigation QMedical Certifier Name Title 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 36 BurialH Date Cemetery,Crematory or Facility Name 04/03/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town, New York Donation 0❑Removal Date Place Removed H and/or and/or Held N Hold Address 0 d Date Point of (/)fTransportation p by Common Shipment 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 —. Remains are Shipped,If Other than Above Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/03/2023 Registrar of Vital Statistics _,YinreeL Ma/iotrey(6'lctronica(lyitgtzed) (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— • Date of Disposition y)j Place of Disposition _ g n` W �7. /address/��� � W N CC (section) (lot number) (grave number) O Name of Sexton or Person in Charge of Premises „ Lift Z (please print) W Signature Title `1aKrYw t i.--l� DOH-1555(07/18)p t of 2 •, r { . TR f "" Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#