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Keen, Constance Jane vaA� Mit - I I filial& I CO MOIL of Vital Records Name First Middle Last Sex Constance Jane Keen Female Date of Death Age If Veteran of U.S.Armed Forces, 09/11/2021 81 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 19 Sugar Pine Road,Queensbury Town, New York 12804 `p Manner of Death © Natural Cause ❑Accident ❑ Homicide ❑Suicide Undetermined ❑Pending Circumstances Investigation WC! Medical Certifier Name Title Darci Gaiotti-Grubbs MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 192 Burial Date Cemetery,Crematory or Facility Name 09/14/2021 Pine View Crematory Entombment Address lCremation Queensbury Town,New York 0 Donation O ElRemoval Date Place Removed and/or and/or Held ~ N Hold Address 0 O. Date Point of u) ❑Transportation p by Common Shipment Carrier Destination ElDisinterment 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 F- Remains are Shipped,If Other than Above 2 Address CC n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/14/2021 Registrar of Vital Statistics Caroline 7fi&&fegar1e Barber(Electronically Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition '1/1 S I/_c Place of Disposition Cre„(+,.Ci r ,2 )AC. CAI) (address) W CC CC (section) (lot number) (grave number) © Name of Sexton or Pers n in Char e of Premises Ti t cM t,}' Sq,u if t,S (please print) W Signature Title CTv 9r'1Or DOH-1555(07/18)p 1 of 2 #osuaon to.2311 stopottu'wound M011-30 Rio'Num otuoti juiatinj alp Suttuosotdou hototooD main oum t OZ uo pannipp jo stuntuai urwnll lizipoox r T (ciz)sti .Da s me qo unt .oficidr