Mandolare, Beverly Jane I l"S,r
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Beverly Jane Mandolare Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/21/2021 88 Years War or Dates
t— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W
W• Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W• Medical Certifier, Name Title
CI 74 Kenneth France MD
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 532
❑Burial Date Cemetery,Crematory or Facility Name
11/23/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
O. Date Point of
Cl) 1-1
Transportation Shipment
p 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
g Address
ft
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/23/2021 Registrar of Vital Statistics Xp6ertAtirew Curtis gkctronicafSrgne9
(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 If IN Ilt Place of Disposition ,.,,(1__ ZA--„,
W (address)
W
CC (section) (lot numbe (grave number)
SName of Sexton or Person in Charge of Premises CX tr r L. ^4lt
Z � ase print)
/
W / Title iiiiii iliik
Signature l
DOH-1555(07/18)p 1 of 2
i%3b
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#