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Fish, Kathy Ann NEW YORK STATE DEPARTMENT OF HEALTH LCFBurial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kathy Ann Fish Female Date of Death Age If Veteran of U.S.Armed Forces, 10/16/2020 63 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Kingsbury Town Street Address 287 Townline Road, Kingsbury Town, New York 12839 p Manner of Death ❑K Natural Cause 0 Accident El Homicide ❑Suicide El Undetermined EI Pending W V Circumstances Investigation W Medical Certifier Name Title 0 Umbreen Rozell MD Address 100 Park Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 31 ©Burial Date Cemetery,Crematory or Facility Name 10/21/2020 Pine View Cemetery 0 E-ntombruent-- Address IDCremation Queensbury Town,New York ❑Donation Z l Removal Date Place Removed and/or and/or Held H Hold Address N 0 Date Point of co 11 Transportation Shipment Q by Common Carrier Destination El Disinterment Date Cemetery Address Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above a Address IX w EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/16/2020 Registrar of Vital Statistics Cyntlrrafl Bardin(EkctronicallySigned) (signature) District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 1 0/2 1 /2020 Place of Disposition21 Quaker Rd. Queensbury, NY 12804 (address) W MOHAWK .117 2 N (section) (lot number) (grave number) CC g Name of Sexton or P rson in Charge of Premises Connie Goedert (please print) W Signature {U4_- Title Superintendent DOH-1555(o7/i8)p 1 of 2 Public Health Law Sec. 4145(2b) u 12 8 1 5 Receipt Human remains of E • delivered on , , 20 ti It 171/ `/, Pe View Cemetery Reprelenting the funeral home named on burial permit Official Funeral Directors Reg.or License#R s- FISH NAME L , Age: Kathy Fish 63 Lot Owner: Harold & Kathy Fish Lot#Mohawk 1 1 7 Grave# 2 Case: Concrete Died:1 0/1 6/2 0 2 0 Interrec�:0/21 /2 0 2 0 Funeral Home: Baker FH Cemetery: Pine View