David, Phoebe Maryann • AI- 53
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Phoebe Maryann David Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/27/2020 87 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 100
▪Burial Date Cemetery,Crematory or Facility Name
11/30/2020 Pine View Crematory
Entombment Address
gCremation Queensbury Town,New York
▪Donation
Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
fn ❑Transportation
p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
0 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
Remains are Shipped,If Other than Above
a Address
CC
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/30/2020 Registrar of Vital Statistics /71inee5Walroll / 'EIectronicallj/SWne4
(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 /10Place of Disposition
4--
2 ( dress)
(section) 7J(lot number) (grave number)
rr
Name of Sexton or Person in Charge of Premises / tit i..r L 59YI AI
(plea e print)/U.! Si nature Zit
J�--� Title l h�+�' .ry,�
DOH-1555 07/18)p t of 2
Public Health Law Sec. 4145(2b) 014 24 6 ��
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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