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Richmond, Nancy L IT ill NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Nancy L. Richmond Female Date of Death Age If Veteran of U.S.Armed Forces, 02/14/2021 87 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Wilton Town Street Address 60 Waller Road,Wilton Town,New York 12831 ILJ `p Manner of Death © Natural Cause 0 Accident ❑Homicide ❑Suicide ElUndetermined ❑Pending IJ U Circumstances Investigation QMedical Certifier Name Title Madison Zuis NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Gansevoort 4569 9 ElBurial Date Cemetery,Crematory or Facility Name 02/16/2021 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,New York ❑Donation Z Removal Date Place Removed o Eland/or and/or Held H Hold Address 0 IL Date Point of t/) 1-1 Transportation 5 by Common Shipment Carrier Destination Date Cemetery Address Ei Disinterment Date Cemetery Address ❑Reinterment 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 F.. Remains are Shipped,If Other than Above 1- Address fr W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/16/2021 Registrar of Vital Statistics Susan Baldwin(Electronically Signed) (signature) District Number 4569 Place Gansevoort, 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 2I i1 111 Place of Disposition —� , ri ILI 2 (address) W L (section) II Plot number (grave number) � O Name of Sexton or Person in Charge of �hn t yw+�lt Premises Z (p4ase print) lL Signature e Title 1-02''147)ifL DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 4'�' ,�k Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#