Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Bement, Donna Mary
Ai"13N1-4 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donna Mary Bement Female Date of Death Age If Veteran of U.S.Armed Forces, 12/22/2020 81 Years War or Dates E- Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital O Manner of Death © Natural Cause 1=1 Accident Homicide 0 Suicide EiUndetermined EIPending UJ Circumstances Investigation �W Medical Certifier Name Title Asim Chaudry MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 589 EiBurial Date Cemetery,Crematory or Facility Name 12/26/2020 Pine View Crematory ❑Entombment Address Cremation Queensbury Town,New York ElDonation o ElRemoval Date Place Removed and/or and/or Held H Hold Address 0 Q. Date Point of U) Li 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 1- Remains are Shipped,If Other than Above a Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/24/2020 Registrar of Vital Statistics Rg6ertAndrew Curtis(ElectronicaQCy 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: Date of Disposition ' -at 2D Place of Disposition �i C (New) e rub 2 (address) W Cl)CC (section) (lot number) (grave number) v C) E. ), 1 Name of Sexton or Person in Char of Pre i s � �A z -(please print) tL Signature ` f Title or,45-1 DOH-t555{07/18)p 1 of 2 0-- Public Health Law Sec. 4145(2b) 0 1 4 3 3 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#