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Laverty, Anna Louise losti NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit I Bureau of Vital Records Name First Middle Last Sex Anna Louise Laverty Female Date of Death Age If Veteran of U.S.Armed Forces, 10/02/2020 57 Years War or Dates p. Place of Death Hospital,Institution or W City,Town or Village South Glens Falls Village Street Address 31 First Street ID,South Glens Falls Village,New York 12803 p• Manner of Death © Natural Cause Accident El Homicide ❑Suicide 1=1Undetermined Pending U Circumstances Investigation IILI Medical Certifier Name Title Susan Hayes-Masa Coroner Address 40 McMaster Street,Ballston Spa, New York 12020 Death Certificate Filed District Number Register Number City,Town or Village South Glens Falls Village 4524 12 0 Burial Date Cemetery,Crematory or Facility Name 10/06/2020 Pine View Crematory -- ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Date Place Removed g Removal and/or and/or Held - Hold Address 0 d Date Point of Cl) L j Transportation p by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address ElReinterment 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 E.. Remains are Shipped,If Other than Above 5 Address W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/05/2020 Registrar of Vital Statistics Shannon Kjlleher(ECectronicallySigned) (signature/ District Number 4524 Place South Glens Falls Village, 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 //6/g lie Place of Disposition ✓Tt—�- 2 (address) W CC (section/ 7trbed (grave number) pName of Sexton or Person in Charge of Prg ' es l�0'`"' ' (pleaseX inl) W /r 4Mn Signature `i Title Wt` DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01 4 0 7'5 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit OfficaK, Funeral Directors Reg.or License#