Eastman, Beverly E. #�3j
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Beverly E.Eastman Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/11/2020 71Years War or Dates
�.. Place of Death Hospital,Institution or
W City,Town or Village Fort Ann Town Street Address 117 Buttermilk Falls Road,Fort Ann Town,New York 12827
tp Mannerof Death ®Natural Cause Accident Homicide Suicide Undetermined Pending
C.y Circumstances Investigation
W Medical Certifier Name Title
Anne Evans DO
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Registe mber
City,Town or Village Fort Ann 5754
❑Burial Date Cemetery,Crematory or Facility Name
03/12/2020 PineView Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO Removal Date Place Removed
and/or and/or Held
U-N Hold Address
0
IL Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/12/2020 Registrar of Vital Statistics Barbara J Winchell(Electronically Signed)
(signature)
District Number 5754 Place Fort Ann, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3 l� Place of Disposition C p!I
(address)
tu
N (section) /� (lot number)C (grave number)
Name of Sexton or Person in Charge of Pre ises
(ple se print)
W Signature Title
DOH-1555(07/18)p 1 of 2
t
Public Health Law Sec. 4145(2b) 013427
Receipt
Human remains of; lj F. - x r, i i' �' delivered on /�� , 20 `'
Pine View'Cemetery Representing the funeral home named o brialpermit
Official Funeral Directors Reg.or License#