Blais, Suzanne NEW YORKSTATE DEPARTMENT OF HEALTH LF Burial - Transit Permit
Bureau of Vial 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
Z City,Town or Village. Fort Edward Town Street Address Fort Hudson Nursing Center Inc
w Manner of Death Undetermined Pending-
®Natural Cause Accident 1:1Homicide. Suicide
W Circumstances DInvestigation
W Medical Certifier Name Title
0 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
Burial Date Cemetery,Crematory or Facility Name
❑ 12/12/2022 Pine View Crematory
Entombment Address
rZ;lCremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
O❑ and/or Held
F- and/or
N
Hold Address i
O —
O- Date Point of
fA❑Transportation ,
p by Common' Shipment
Carrier Destination
Disinterment
Date Cemetery AddressEl
1
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
W
a; Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/12/2022 Registrar of Vital Statistics fgzkeeLMalroney(ElectronzcalyS6we4
(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:
F-
Z Date of Disposition 12 112IZZ, Place of Disposition L
W address)
2
W
N (section) (tot number) (grave number)
Name of or Person n Charge remises H
0 A
N f St P i Ch
Z fP1qfSePrmT1
LU Signature Title
DOH-1555(07/18)p t of 2
- - 01 64u`3
Public Health Law Sec. 4145(2b)
la . 5,
Receipt
Human remains of-�- _ t . �' �`delivered on r , 20``'
kvioewc
emetery '' Representing the funeral home named on burial permit
Funeral Directors Reg.or License# �`?ram
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