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Carey, Lois Ann f g NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit 'I Bureau of Vital Records Name First Middle Last Sex Lois Ann Carey Female Date of Death Age If Veteran of U.S.Armed Forces, 10/12/2020 71 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc W • `p Manner of Death © Natural Cause 1=I Accident ❑Homicide ❑Suicide ❑Undetermined Pending Circumstances Investigation W Medical Certifier Name Title O Eileen Spinelli NP Address 319 Broadway, Fort Edward Town, New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 84 ElBurial Date Cemetery,Crematory or Facility Name 10/13/2020 Pine View Crematory ElEntombment Address QCremation Queensbury Town,New York ElDonation Z Removal Date Place Removed and/or and/or Held H N Hold Address 0 Date Point of U) ❑Transportation p 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-Fort Edward 01079 Address 82 Broadway,Fort Edward, New York 12828 Name of Funeral Firm Making Disposition or to Whom p— Remains are Shipped,If Other than Above 2 Address W Q" Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/13/2020 Registrar of Vital Statistics Aimee Mahoney(Efectronicaffy 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 AL Ir Z Date of Disposition 10111,,(t() Place of Disposition ��,. UJ (address) LLI (section) g (lot number) (grave number) Name of Sexton or Person in Cha of PremisesV ( L se print)S Z W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) ' �' 4 ° Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#