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Williams, Lovila 4r g6'S NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit ew. Name First Middle Last Sex 04. Lovila Williams Female Date of Death Age If Veteran of U.S. Armed Forces, October 15, 2021 tAf^^r War or Dates , Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address Manner of Death IJ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation . Medical Certifier Name Title Elizabeth Cooney, DR. Address 100 Park St Glens Falls, NY 12801 fp Deat. - - ificate Filed District Number Register Number Ci , Town .r Village QW1 I 0 Bun- Date Cemetery or Crematory October 25, 2021 Pine View Crematorium ❑Entombment Address :: ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier t ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address ri Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address 7 , Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 ; Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address t. '.'-' Permission is hereby granted to dispose of the human r mains escr' e above as indicated. Date Issued(c\ I Registrar of Vital Statistics C---.._ i (signature) District Number'SC9c') Place l UL-�(- c ('L,,o n.,ti� A I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 10/25/2021 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) (lot number) (grave number) L Name of Sexton or Person in Charge of Premis `�rs ^,411 ;' (p�se print) Signature / Title 64102 (over) DOH-1555(02/2004) 5252 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named,on bupal permit Official Funeral Directors Reg.or License#