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Cleavland, BeverlyNEW YORKSTATE DEPARTMENT OF HEALTH Bureau of Vital Records L # bYsr Burial -Transit Permit Name First Middle Last Sex Beverly Cecelia Cleavland Female Date of Death Age If Veteran of U.S. Armed Forces, 09/30/2019 92 Years War or Dates II.— Place of Death Hospital, Institution or WCity, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death ©Natural Cause Accident Homicide Suicide Undetermined Pending p Circumstances Investigation WMedical Certifier Name Title Scott Biasetti MD Address 100 Park St, Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 421 ❑ Burial Date Cemetery, Crematory or Facility Name 10/01/2019 Pine View Crematory Entombment Address X❑ Cremation Queensbury Town, New York Donation Z Removal Date Place Removed r � and/or and/or Held _ H Hold Address N O 0. Date Point of to p Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address 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 E— Remains are Shipped, If Other than Above Address W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/30/2019 Registrar of Vital Statistics &6ert gndrew Curtis (2GYectronicaCCy Signed (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition JO /7, 15 Place of Disposition ( 'f �r W (address) W NIM (section) (iot number) (grave number/ O 3("'A-PL—5,J-AIT C3 Name of Sexton or Person in Charge of Premises Z (please print/ W Signature Title 2- DO H-1555 (07/18) p 1 of 2 Public Health Law Sec. 4145(2b) 012571 Receipt Human remains of -\ delivered on �� C Pine View Cemetery Official , 20 - 1 Representing the funeral home named on burial permit Funeral Directors Reg. or License # ,,,-% - - - -