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Jeffords, Beulah Martha 5Z2 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Beulah Martha Jeffords Female Date of Death Age If Veteran of U.S.Armed Forces, 06/23/2021 71 Years War or Dates unknown Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death © Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined Pending IL Circumstances Investigation W Medical Certifier Name Title Cl Asim Chaudry MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 257 ❑Burial Date Cemetery,Crematory or Facility Name 06/25/2021 Pine View Crematory ❑Entombment Address Cremation Queensbury Town,New York ❑Donation is ❑Removal Date Place Removed and/or and/or Held - Hold Address 0 d Date Point of N ❑Transportation by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address CC O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/24/2021 Registrar of Vital Statistics gWertAndrew Curtis(ECectronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IF- W Date of Disposition is-lig Place of Disposition a/n,A_ 2 (address) W CC N (section) a (lot number) (g rave number) {� O Name of Sexton or Person in Charge of remises !1F �, �,L'61 (pte print) W Signature Title rr 1( DOH-1555(o7/18)p t of 2 t i Public Health Law Sec. 4145(2b) 0 ._ , 4,dt 0 1 1 1 Receipt t Human remains of delivered on i , 20 1 1 1 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# 1