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Cossey, Jessica L. 3s NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jessica L.Cossey A.K.A.Jessica L.Long Female Date of Death Age If Veteran of U.S.Armed Forces, 04/13/2021 34 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Lake Luzerne Town Street Address 41 Potash Road, Lake Luzerne Town, New York 12846 p Manner of Death El Natural Cause ❑Accident ❑Homicide Suicide Undetermined ©Pending Circumstances Investigation Medical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town, New York 12845 Death Certificate Filed -• District Number Register Number •'; ` 5656 5 City,Town or Village d,.,�"l {l@ Luzerne ElBurial Date • E,' : Cemetery,Crematory or Facility Name 04/1 Pine View Crematory El EntombmentAdd3's" 0 Cremation Queensbury Town,New York Donation o Removal Date Place Removed and/or and/or Held I Hold Address CO 0 O. Date Point of CJ) ❑Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address 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 H Remains are Shipped,If Other than Above a Address Q W d Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/14/2021 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 thi it on: 7 I- WDate of Disposition Li/I5'171 Place of Disposition `�.- Z4, 2 (address) W U) CC (section) number) (grave number) ir 0 Name of Sexton or Person in Charge of Premises r ` �t'`^'l Z 'a /Please in1J WSignature L� Title (Wm OW DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 14 7 1 9 Receipt Human remains of - delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# '