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Bouchard, Faith Ann ii- LI)/ NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Faith Ann Bouchard Female Date of Death Age If Veteran of U.S.Armed Forces, 05/09/2021 71 Years War or Dates IH Place of Death Hospital,Institution or Z City,Town or Village Minerva Town Street Address 1590 Route 28 N,Minerva Town,New York 12851 Wp Manner of Death © Natural Cause ElAccident ❑Homicide 0 Suicide El Undetermined 0 Pending ILI 0 Circumstances Investigation W Medical Certifier Name Title 0 Jay Heald Coroner Address 7521 Court Street,Elizabethtown Town, New York 12932 Death Certificate Filed District Number Register Number City,Town or Village Olmstedville 1557 10 Burial Date Cemetery,Crematory or Facility Name 05/12/2021 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation Z 0 Removal Date Place Removed and/or and/or Held i Hold Address N 0 Date Point of U) L j Transportation Shipment Q by Common Carrier Destination Date Cemetery Address ❑Disinterment Date Ceriietery 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 Address Q W fl' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/12/2021 Registrar of Vital Statistics Ana Mason(ECectronica((y Signed) (signature) District Number 1557 Place Olmstedville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 W Date of Disposition 5 ilj[Li Place of Disposition �ie-`L- ----- (address) W CC (section) (lot number) (grave number) Q Name of Sexton or Person in Charge of Premises lir" L 5� 11 Z (pleasd print) W i \ Title (21Cr.j�4 Signature DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) °4.7 8 2 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit y Official Funeral Directors Reg.or License#