Fuller, Misty Lee NEW YORKSTATE DEPARTMENT OF HF ,LTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Misty Lee Fuller ry Female
Date of Death Age if Veteran of U.S.Armed Forces,
09/13/2021 42 Years War or Dates
!H Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address 414 Lower Main Street, Fort Edward Town,New York 12839
pManner of Death Natural Cause p Accident ❑Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
W• Medical Certifier Name Title
Robert Lemieux Coroner
Address
415 Lower Main Street, Hudson Falls Village, New York 12839
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 53
❑Burial Date Cemetery,Crematory or Facility Name
09/14/2021 Pine View Crematory
❑Entombment Address
lCremation Queensbury Town,New York
ElDonation
•
• Removal Date Place Removed
and/or and/or Held
H
N Hold Address
0
Date Point of
U) Li Transportation Shipment
Q by Common
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
2 Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/14/2021 Registrar of Vital Statistics Aimee L Mahoney(ECectronicalTy 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:
Date of Disposition • Place of Disposition Cfr. 4.0cY
(address)
LIJ
Q (section) (lot number) (grave number)
Texe^ S c6u;{vs
Name of Sexton or Person in Charge of Premises (please print)
W Title /i'`c'7 �`
Signature
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b) z . . - '.. .;,. %• , '
Receipt
Human remains of ' ° , ' ' " ,,.
' :-- delivered on ' :' : , 20
Pine View Cemetery Representing the fuheral home named on burialAraimit
Official Funeral Directors Reg. or License#' - ' ', •