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Cerro, Michelle Rolande NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records BUrldt - Transit Permit�0 Z Name First Middle Last Sex Michelle Rolande Cerro Female Date of Death Age If Veteran of U.S.Armed Forces, 05/12/2020 78 Years War or Dates ,. Place of Death Hospital,Institution or City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc LU Q Manner of Death © Natural Cause Accident 1:1Homicide Suicide ❑Undetermined Pending Llij Circumstances Investigation WMedical Certifier Name Title John Quaresima MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 48 ❑Burial Date Cemetery,Crematory or Facility Name 05/14/2020 -T Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation ORemoval Date Place Removed and/or and/or Held N Hold Address O a Date Point of to Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address JE]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 (L Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/13/2020 Registrar of Vital Statistics 4imee94ahoney(ECectronicalTySigned) (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: W Date of Disposition �_/L �-J "Zp Z O Place of Disposition i h >✓�►2c� GI 'L rn L (address) W M 0 (section) (lot number) (grave number) aName of Sexton or Person i arge remises 1 t� C-- r� Z (please print) / W' Signature Title DO H-1555(07/18)p 1 of 2 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#