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Kosby, Amelia 11�7/ NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Amelia Kosby Female Date of Death Age If Veteran of U.S.Armed Forces, 12/29/2021 92 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 8 Elizabeth Lane,Queensbury Town, New York 12804 `p Manner of Death ©Natural Cause ❑Accident Homicide ❑Suicide Undetermined ElPending U Circumstances Investigation 0 Medical Certifier Name Title Laurie Dennison NP Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 254 ❑Burial Date Cemetery,Crematory or Facility Name 12/30/2021 Pine View Crematory Entombment Address lCremation Queensbury Town,New York Donation 0 ❑Removal Date Place Removed and/or and/or Held Hold Address N 0 co Li Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address 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 N Remains are Shipped,If Other than Above 2 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/30/2021 Registrar of Vital Statistics Caroline 7fiCdegarde Barber(Electronically Signed) (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: W Date of Disposition I 1 4 IZZ Place of Disposition 2 (address) W CC t/) (section) t number) C (grave number) gName of Sexton or Person in Charge419 ff Pre ' s A� (t Z (please rint) W Signature Title ++ ( 1,�Q DOH-1555(07/18)pi of 2 I Public Health Law Sec. 4145(2b) Receipt I Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#