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Etu, Elise Louise 4c NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Elsie Louise Etu Female Date of Death Age If Veteran of U.S.Armed Forces, 10/26/2021 88 Years War or Dates f.. Place of Death Hospital,Institution or QZ City,Town 6r Village Fort Edward Village Street Address 12 Frank Street, Fort Edward Village, New York 12828 Manner of Death ©Natural Cause 0 Accident El Homicide El Suicide El Undetermined ❑Pending W U Circumstances Investigation LU Medical Certifier Name Title William Parker MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 64 ElBurial Date Cemetery,Crematory or Facility Name 10/27/2021 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town,New York IDDonation ElRemoval Date Place Removed Ir. and/or and/or Held N Hold Address 0 IL Date Point of N Transportation p by Common Shipment Carrier Destination EIDisinterment 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 Fire Making Disposition or to Whom f- Remains are Sbipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/27/2021 Registrar of Vital Statistics Aimee L Mahoney(Electronically 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 o�n j: V W Date of Disposition �OIZ$�1( Place of Disposition �/,� ,� �-6_ 2 (address) W U) CC (sedionJ (lot number) y (grave number) 0 Name of Sexton or Person in Charge of Premis /�ti'�S �, t°v���V Z ! (plea e print/ W Signature n Title c raidiit'lli l I,IL DOH-1555(07/18)pi of 2 Public Health Law Sec. 4145(2b) 015264 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the fun ral home name\4 n burial permit Official Funeral Directors Reg.or License#