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Brockway, Annette Lois fl NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Per it Bureau of Vitat Records Name First Middle Last Sex Annette Lois Brockway Female Date of Death Age If Veteran of U.S.Armed Forces, 05/28/2021 82 Years War or Dates 1957-1959 Place of Death Hospital,Institution or W City,Town or Village Fort Edward Town Street Address 187 Williams Road, Fort Edward Town,New York 12828 p Manner of Death © Natural Cause ❑Accident ❑Homicide El Suicide Undetermined El Pending W Circumstances Investigation W• Medical Certifier Name Title O Eileen Spinelli NP Address Carey Rd,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 29 ElBurial Date Cemetery,Crematory or Facility Name 06/02/2021 Pine View Crematory Entombment Address ElCremation Queensbury Town,New York ElDonation 0 Removal Date Place Removed and/or and/or Held N Hold Address 0 O. Date Point of N ❑Transportation Shipment by Common Carrier Destination 0 Disinterment Date Cemetery Address El 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 F. Remains are Shipped,If Other than Above a Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/01/2021 Registrar of Vital Statistics Aimee L Mahoney(Electronically Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ,� W Date of Disposition (p I i l It Place of Disposition (address) //1 -- W re N (section) (lot tuber) (grave number) 0 Name of Sexton or Person in Charge of Premises �`� S ft Z ( ease prin) W e'r6M,i Signature Title DOH-1555(o7/18)p t of 2 Public Health Law Sec. 4145(2b) 014 819 J Receipt Human remains of I delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#