Fonda, Joan O 44- IIV
. II
NEW YORK STATE DEPARTMENT OF HEALTH _ `� Burial - Transit Permit
Bureau of Vital Records
Name First Middle "• Last Sex
Joan O.Fonda Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/10/2023 86 Years War or Dates
1.,. 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 n Undetermined ❑Pending
El Natural Cause nAccident I I Homicide Suicide
W Circumstances Investigation
CI Title
W Medical Certifier Name
CI Nicole Humiston NP
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 91
RBurial Date Cemetery,Crematory or Facility Name
11/15/2023 Pine View Crematory
Entombment Address
lgiCremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
U)
0
Date Point of
Cl)❑Transportation Shipment
p by Common
Carrier Destination
O
Disinterment
Date Cemetery Address
Ei 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
l- 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 11/14/2023 Registrar of Vital Statistics ,7imeeLalalroney(EYectronicalrSzmned)
(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 A I'S-In Place of Disposition 'Tc?:A)y 6.J titr,in ii 1 (,(!ti1
2 (address)
1J1
U)CC (section) A
(lot number/ (grave number)
0 Name of Sexton or Person in Charge oEz,,,,:ofremises %`A
lease print/
Z
Ill
Title 1-ifnikPI
DOH-t555(o7/18)p 1 of 2
G
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#