Conlee, Mary Lucille it ‘c3
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Lucille Conlee Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/01/2021 86 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
W Manner of Death Natural Cause tEl Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
0 Circumstances Investigation
Q Medical Certifier Name Title
Gwendolyn Morris-Dickinson PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 41
❑Burial Date Cemetery,Crematory or Facility Name
08/03/2021 Pine View Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
❑Donation
Date Place Removed
O• ❑Removal and/or Held
and/or
Hold Address
0
CL(I) Transportation Date Point of
❑
Clby 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
1-. Remains are Shipped,If Other than Above
S Address
C
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/03/2021 Registrar of Vital Statistics Aimee L 9Kahoney(6CectronicaCTy 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:
l•- i
Date of Disposition 813 14 Place of Disposition r�
ILI
2 (address)
W
N
CC (section) j (lot number) J� (grave number)
O Name of Sexton or Person in Charge o remises I. L �t Ul
Z (pse print)
IW A„
Signature Title w�✓�
DOH-1555(07/18)p 1 of 2
IP
1 Public Health Law Sec. 4145(2b) 0 b
1
Receipt
Human remains of delivered on , 20
•
•
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
1