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Graham, Donna Jean NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Donna Jean Graham Female Date of Death Age If Veteran of U.S.Armed Forces, 08/20/2021 73 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital lL Manner of Death © ❑ ❑ ❑ ❑Undetermined ❑Pending Natural Cause Accident Homicide Suicide W Circumstances Investigation W Medical Certifier Name Title Gamal Khalifa MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 351 ❑Burial Date Cemetery,Crematory or Facility Name 08/23/2021 Pine View Crematory ❑Entombment Address E1Cremation Queensbury Town,New York ❑Donation Z El Removal Date Place Removed and/or and/or Held Hold Address N 0 CL Date Point of Cl) LiTransportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Date Cemetery Address ❑Reinterment 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 F Remains are Shipped,If Other than Above Address CC W • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/23/2021 Registrar of Vital Statistics WobertAndrew Curtis((Electronically 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: Z Date of Disposition IR-23-202/ Place of Disposition Prit .,. ,f r�,,. �r 2 (addres97 W CC (section) \ (lot number) (grave number) 0 Name of Sexton or Pers in Ch rge of Premises ^Jln.f!�-N (94*i, ad,6-- Z (please print) W Signature Title e—re-`-er OpCt/ec DOH-1555(07/18)p 1 of 2 . 0 0:1, 5 G 6 1 Public Health Law Sec. 4145(2b) Receipt Human remains of '''t' '. -, ,','''a"-— delivered on ' - '/ , 20 y Pine View Cemetery Representing the funeral home named pu burial permit , ..._- Official Funeral Directors Reg.ortlrefi§e# - -