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Lockhart, Beverly Ann 4 127 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Beverly Ann Lockhart Female Date of Death Age If Veteran of U.S.Armed Forces, 10/29/2021 82 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 57 Sweet Route,Queensbury Town, New York 12804 W Manner of Death © W Natural Cause 0 Accident EI Homicide Suicide Undetermined Ei Pending C.) Circumstances Investigation C Medical Certifier Name Title Robert Love MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 213 ❑Burial Date Cemetery,Crematory or Facility Name 11/02/2021 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York ❑Donation 0 Removal Date Place Removed and/or and/or Held H Hold Address 0 D. Date Point of U) Li Transportation p by Common Shipment Carrier Destination 0 Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 2 Address C Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/02/2021 Registrar of Vital Statistics Carolinex1tfegarie Bar6er(ECectronica[IySigned) (signature) District Number 5657 Place Queensbury, 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 11 13114 Place of Disposition X'iti.U11_ (,,,CILI �,,. 2 (address) W CC (section) (tot number) (grave number) 0 Name of Sexton or Person in Char•-of Premises ( 1(q �� k Z ( ease print) LU Signature Title 1� / DOH-1555(07/18)p t of 2 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#