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Lefebvre, Carmen B oerak sh4 n NEW YORK STATE DEPARTMENT OF HEALTH �� X Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Carmen B.Lefebvre Female Date of Death Age If Veteran of U.S.Armed Forces, 12/15/2021 77 Years War or Dates N Place of Death Hospital,Institution or WCity,Town or Village Moreau Town Street Address 46 Fort Edward Road, Moreau Town, New York 12828 p Manner of Death © Natural Cause ❑Accident ❑Homicide 1=I Suicide 0 Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title O Robert Love MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 61 ElBurial Date Cemetery,Crematory or Facility Name 12/15/2021 Pine View Crematory Entombment —Address O Cremation Queensbury Town,New York ▪Donation z Removal Date Place Removed 6 and/or and/or Held F Hold Address N 0 Date Point of N ❑Transportation Shipment Q by Common — — Carrier Destination Date Cemetery Address ❑Disinterment 0 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above 2 Address Q Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/15/2021 Registrar of Vital Statistics Geeann Mc ca6e(ECectronicallySigned) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1— WDate of Disposition 1 4)0fti Place of Disposition "F.4. 0address/ otrLi_ W CC (section) (lot number) (grave number) Q Name of Sexton or Person in Charge of Premi es G t(ti 04✓� L.� (pleaje print) Z L� rfvi.4 W Signature -t— Title 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 burin permit Official Funeral Directors Reg.or License#