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Grant, Cheryl Ann N NEW YORK STATE DEPARTMENT OF HEALTH I Bureau of Vital Records / ' *; Burial - Transit Per it Name First Middle Last Sex Cheryl Ann Grant Female Date of Death Age If Veteran of U.S.Armed Forces, 11/06/2021 65 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing p Manner of Death © Natural Cause 0 Accident Homicide ❑Suicide Undetermined 0 Pending W U Circumstances Investigation WQ Medical Certifier Name Title Shardul Koppar DO Address 17 Madison St,Granville Village,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville Village 5725 57 Burial Date Cemetery,Crematory or Facility Name 11/08/2021 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held U) Hold Address 0 a- Date Point of U) ❑Transportation f by Common Shipment Carrier Destination 0 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 Address C al n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/08/2021 Registrar of Vital Statistics 24chard Merts(ECectronicaCCySigned) (signature) District Number 5725 Place Granville Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition IIZI Place of Disposition ,l/ 2 (address) W U) (section) / (lot number) (grave number) cl• Name of Sexton or Person in Charge of P miles L � h s i_ ./1� Z7 (Plea print) UJ Signature 6�� Title 4 ' �1( DOH-1555(07/18)pi of 2 1 . . 1 1 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 i Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#