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Havens, Sharon Anne RP NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Sharon Anne Havens Female Date of Death Age If Veteran of U.S.Armed Forces, 11/22/2020 72 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Pending � © Natural Cause Accident Homicide Suicide �Undetermined W Circumstances Investigation W Medical Certifier Name Title CI Kelly Maley PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 528 Burial I Date Cemetery,Crematory or Facility Name 11/24/2020 Pine View Crematory Entombment Address Cremation Queensbury Town,New York EiDonation Removal Date Place Removed and/or and/or Held N Hold Address O n. Date Point of co Li Transportation Shipment Q by Common 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 Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/24/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically 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: H �( Z Date of Disposition 111 73 120 Place of Disposition 2 (address) W N CC (section) (lot number) (grave number) G Name of Sexton or Person in Charge of Pre ises '11; _ �DM�CHI (pleas print) Z / W Signature < Title 41 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 1422.5 Receipt Human remains of delivered on , 20 � Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#