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Bailey, Evelyn Charlotte A NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Evelyn Charlotte Bailey Female Date of Death Age If Veteran of U.S.Armed Forces, 12/28/2020 85 Years War or Dates i_ Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death © Natural Cause ❑Accident 0 Homicide El Suicide 0 Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title CI Aaron Heckler PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 602 EIBurial Date Cemetery,Crematory or Facility Name 12/31/2020 Pine View Crematory Entombment Address ElCremation Queensbury Town,New York ElDonation Z Removal Date Place Removed and/or and/or Held f- Hold Address N 0 Date Point of N L j Transportation Shipment p by Common Carrier Destination ID Disinterment Date Cemetery Address Date Cemetery Address ElReinterment 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 H Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/30/2020 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: I— Z Date of Disposition 1-0?-2o2 / Place of Disposition �; �i e V..1..v (':t-07,1 UJ-,{ W dress) 2 W to (section) (lot number) A (grave number) CC O Name of Sexton or Person in Charge of Prem. s r���' °c Z /(pleasele print) ill Signature j./r'i1 Title or DOH-1555(07/18)p 1 of 2 nn Public Health Law Sec. 4145(2b) 0I 3 pc Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#