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McCullough, Majorie J tip/c NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Marjorie J.McCullough Female Date of Death Age If Veteran of U.S.Armed Forces, 12/13/2021 83 Years War or Dates Place of Death Hospital,Institution or Z- City,Town or Village Corinth Town Street Address 3 Gobel Avenue,Corinth Town, New York 12822 pManner of Death ©Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined El Pending W V Circumstances Investigation W Medical Certifier Name Title CI Felicia Phillips NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Corinth 4553 25 ❑Burial Date Cemetery,Crematory or Facility Name 12/14/2021 Pine View Crematory ❑Entombment Address IDCremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held H Hold Address 0 Date Point of NU Transportation Shipment Q by Common Carrier Destination Date Cemetery Address ❑Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 5 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/14/2021 Registrar of Vital Statistics Brenda L Peris(Electronically Signed) (signature) District Number 4553 Place Corinth, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IH Z Date of Disposition Rigs IZf Place of Disposition W (address) W CC N (section) (lot number) (grave number) a Name of Sexton or Person in Charge of Pr ises `� C1 (plea print) Z /1ttC . ,A�,n W Signature Title (� 1'�ryt�Ic DOH-1555(07/18)p 1 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#