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Wadsworth, Holly Ann
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Holly Ann Wadsworth Female { Date of Death Ale If Veteran of U.S.Armed Forces, :�. 03/27/2020 61 Years War orDates Place of Death Hospital,Institution or City,Town or Village Fort Edward Village Street Address 8 Cortland Street, Fort Edward Village, New York 12828 Manner of Death ©Natural Cause Accident Homicide Suicide Undetermined Ej Pending Circumstances Investigation Medical Certifier Name Title Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town orVilla a Fort Edward 5755 24 Burial Date Cemetery,Crematory or Facility Name 03/30/2020 Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation 12 ❑Removal Date Place Removed +� and/or and/or Held n' Hold Address a Transportation Date Point of p by Common Shipment Carrier Destination "'. El 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 Otherthan Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/30/2020 Registrar of Vital Statistics Aimee Mahoney(Electronically Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: +��' Date of Disposition 3(3o Zo Place of Disposition 7 fWr. a dress/ (section) (grave number) Name of Sexton or Person in Charge of Premises (p ase print) Signature Title DO H-1555(07/18)p 1 of 2 3 Public Health Law Sec. 4145(2b) 013482 o, Receipt Human remains of elivered on ? , 20 - r� Yfne View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#