Sellingham, Beverly Agnes -4 313
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Beverly Agnes Sellingham Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/23/2021 95 Years War or Dates
F. Place of Death Hospital,Institution or
W City,Town or Village Argyle Town Street Address 2321 Lick Springs Road,Argyle Town, New York 12809
p Manner of Death xi NaturalCause 1=1Accident Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
11J Medical Certifier Name Title
0 Mary Stein NP
Address
9 Carey Road,Queensbury To$N,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Argyle 5750 30
❑Burial Date Cemetery,Crematory or Facility Name
04/26/2021 Pine View Crematory
❑Entombment Address
MCremation Queensbury Town,New York
ElDonation
ZRemoval Date Place Removed
El
and/or and/or Held
H Hold Address
N
0
d Date Point of
Cl) ❑Transportation
p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
11 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above ___
a Address
CC
W
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/26/2021 Registrar of Vital Statistics Shelley Mckernon(E(ectronically Signed)
(signature)
District Number 5750 Place Argyle, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition i'in!i Place of Disposition Fia—, r'----
2 (address)
W
Cl)
CC (section) 4 (lot number) ` (grave number)
gName of Sexton or Person in Charge of Premises /1 , k+. i t, s...A t
Z j
(p! se print)
W Signature Title � �"�
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) - i 1 7 4
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#