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Yberg, Jean M NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit 11 Bureau of Vital Records Name First Middle Last Sex Jean M Yberg Female Date of Death Age If Veteran of U.S.Armed Forces, 01/24/2021 92 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Lake Luzerne Town Street Address 191 Beartown Road, Lake Luzerne Town,New York 12846 111 up Manner of Death ©Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined El Pending U Circumstances Investigation W Medical Certifier Name Title 0 Laurie Dennison NP Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Lake Luzerne 5656 1 ❑Burial Date Cemetery,Crematory or Facility Name 01/26/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York Donation ZZ• Removal Date Place Removed and/or and/or Held H Hold Address N 0 CL Date Point of COU Transportation p by Common Shipment Carrier Destination Ei Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 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 01/26/2021 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed) (signature) District Number 5656 Place Lake Luzerne, 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 1/ZIo ill Place of Disposition1L 6✓4o r,,—... W (address) W NCC (section) 4 (lot number) (grave number) Name of Sexton or Person in CharZ ge omises r 0 �'"n.�l{ 7, (pl se print/ P Lu W Signature Title /h°' M 1 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014,4 uO Receipt Human remains of ti delivered on , 20 t Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# `