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Haywood, Amber Lynn KSTATEDEPARTMENTOFHEALTH - Transit YOR BurialTransit Permit Bureau of Vital Records Name First Middle Last Sex Amber Lynn Haywood Female Date of Death Age If Veteran of .S.Armed Forces, 01/19/2021 48 Years War or Dates 1,.. Place of Death Hospital,Institution or Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing LU Manner of Death Undetermined ❑Pending O © Natural Cause �Accident �Homicide �Suicide W v Circumstances Investigation W Medical Certifier Name Title O Leonard Gelman MD Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 2 Burial Date Cemetery,Crematory or Facility Name 01/21/2021 Pine View Crematory Entombment Address ElCremation Queensbury Town,New York ❑Donation Z Removal Date Place Removed O EJ- and/or and/or Held H- Hold Address N O Date Point of co Li Transportation Shipment p by Common Carrier Destination Date Cemetery Address ❑Disinterment Date Cemetery Address ❑Reinterment 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 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/21/2021 Registrar of Vital Statistics Jenny Linda M Martelle(Electronically Signed) (signature) District Number 5756 Place Granville, 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 I/ZZiIf Place of Disposition LL W /ad dress/71;*/ W U) CC (section) / (lot number) (grave number) a Name of Sexton or Person in Charge of Pre ises ` ri' J roan (pie se print/ z /rl�r� LU Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 314 4 4 3 Receipt 1 Human remains of delivered on , 20 1 i Pine View Cemetery Official Representing the funeral home named on burial permit Funeral Directors Reg.or License# i 1