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Antis, Mary Eleanor NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mary Eleanor Antis Female Date of Death Age If Veteran of U.S.Armed Forces, 06/10/2021 64 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Moreau Town Street Address 11 Paris Road,Moreau Town,New York 12828 p Manner of Death © Natural Cause El Accident ❑Homicide El Suicide El Undetermined Pending W C.) Circumstances Investigation W Medical Certifier Name Title C) Daniel Kredentser MD Address 391 Myrtle Avenue 2,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 30 EiBurial Date Cemetery,Crematory or Facility Name 06/14/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York EiDonation Z Removal Date Place Removed and/or and/or Held H Hold Address 0 Date Point of N ❑Transportation Shipment p by Common Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 1— Remains are Shipped,If Other than Above g Address Cr W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/14/2021 Registrar of Vital Statistics Leeann Mc cabe(Electronically Signed) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: �J i Z Date of Disposition to f/11'�,1 Place of Disposition ,�,1l� (address) W N (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Pre s r4 4 (Pase print) Z C W Signature Title DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01 La M, Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#