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Williams, Beverly rel Town of Queensbury Certification of Cremation Pine View Cemetery and Crematory This certifies that the remains of: Beverly Williams were cremated on November , 22 20 21 at the Pine View (Month) (Day) Crematorium, Queensbury, New York, and these are the cremated remains of said body. Date of Death November , 19 20 21 Age 58 (Month) (Day) Funeral Home Regan Denny Stafford Registered No. 986 7...,.'1:771 Zs---- (Authorized Signature) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Beverly Jean Williams Female Date of Death Age If Veteran of U.S.Armed Forces, 11/19/2021 58 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Valatie Village Street Address Barnwell Nursing And Rehabilitation Center W Manner of Death Pending C ©Natural Cause �Accident �Homicide �Suicide �Undetermined � W U Circumstances Investigation 111 0 Medical Certifier Name Title Kathleen Steiger NP Address 3230 Church St,Valatie Village,New York 12184 Death Certificate Filed District Number Register Number City,Town or Village Valatie Village 1023 68 ❑Burial Date Cemetery,Crematory or Facility Name 11/22/2021 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury,New York ❑Donation Z Removal Date Place Removed - and/or and/or Held H- Hold Address N 0 a. Date Point of U) ❑Transportation Shipment G by Common Carrier Destination Date Cemetery Address ❑Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above a Address Q al O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/21/2021 Registrar of Vital Statistics Barbara Ann Tischer(ECectronicaCtySigned) (signature) District Number 1023 Place Valatie Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Date of Disposition (j LZ I Zi Place of Disposition ?„4,..... ZAV----- 2 (address) W NCC (section) A(lot number) (grave number) 8 Name of Sexton or Person in Charge of Pre 'ses tilt,i a ,o abtt z �jt /Plea print/ W Signature l//!J//// Title RQ g DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of _._delivered on , 20T Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# Williams NAME Beverly Williams Age: 58 Lot Owner: Harold & Beatrice Rathbun Lot# Mohican 47E Grave# 4 Case: Urn Died: 1 1 . 1 9.21 Interred:1 1 .27 .21 Funeral Home: Regan Denny Stafford Cemetery: Pine View RATHBUNLUF Lot No. 47 idress Moon _Hill goad R.D. Lake George, NY 12845 Section No. wner Harold & Beatrice Rathbun Plot Mohican ate 9/3/92 Approx. 33 Superficial ft. @ )cation Bounded on North by Stockwell , South by Vacant , East by Vacant , West by Vacant . corner Posts emarks eed No. (and changes) 2469 iyment Record Paid in Full 9/3/92 cord of Interments Harold A. Rathbun 7/30/93 (C-42-EN. ,—) —i ,,�}' BEATRICE W. RATHBURN 1/30/06 (CREM) V Ctil I� a_� i'j 1,0iI\tG(115 - iI • . 7 GR ICS r k w //6 . win No. of giQL