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Freeman, ShirleyoL NEW YORKSTATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex I Shirley Ann Freeman Female Date of Death Age If Veteran of U.S. Armed Forces, 10/22/2019 79 Years War or Dates IF— Place of Death Hospital, Institution or WCity, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc Mannerof Death © Natural Cause ElAccident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title © Michael Miles MD Address 319 Broadway, Fort Edward Town, New York 12828 Death Certificate Filed District Number Register Number City, Town or Village Fort Edward 5755 87 F0 Burial Date Cemetery, Crematory or Facility Name Entombment 10/22/2019 Pine View Crematory Address X❑ Cremation Queensbury Town, New York ❑ Donation Date Place Removed ©❑Removal and/or Held H and/or ro Hold Address Off. Date Point of N ❑ Transportation Shipment p by Common Carrier Destination 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 IN Remains are Shipped, If Other than Above Address W 0" Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/22/2019 Registrar of Vital Statistics Aimee Mahoney (ECectronicaCCy 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: Z Date of Disposition p 114 111 Place of Disposition w(address) W U) (section) (lot number) (grave number) SName of Sexton or Person in Charge of Premises /p ase print/ r �/, /J W Signature �' �� Title l"l DOH-1555 (07/18) p 1 of 2 Public Health Law Sec. 4145(2b) 013016 Receipt Human remains of delivered on 20 Pine View Cethetery Representing the funeral home named on burial ermit # Official Funeral Directors Reg. or License