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Ferguson, Opal Mae A ‘a NEW YORK STATE DEPARTMENT OF HEALTH 4r) Burial - Transit Permit Bureau of Vital Records Name First Middle ` ' Last Sex Opal Mae Ferguson Female Date of Death Age If Veteran of U.S.Armed Forces, 01/17/2022 90 Years War or Dates F- Place of Death Hospital,Institution or WCity,Town or Village Moreau Town Street Address 152 Lamplighter Acres,Moreau Town, New York 12828 p Manner of Death © Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined ❑Pending W C.) Circumstances Investigation W Medical Certifier Name Title CI Mark Quaresima MD _. Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 4 ▪Burial Date Cemetery,Crematory or Facility Name 01/19/2022 Pine View Crematory Entombment Address lCremation Queensbury Town,New York ❑Donation IS ❑Removal Date Place Removed and/or and/or Held Hold Address CA LL Date Point of N 1-1 Transportation Shipment Q by Common Carrier Destination • El Disinterment Date Cemetery Address EIReinterment 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 E,. Remains are Shipped,If Other than Above 2. Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/19/2022 Registrar of Vital Statistics Leeann Mc case(E(ectronica((y Signed) (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: Z Date of Disposition ill Place of Disposition '�h.SL Z4v--- LU W /201t2 (address) CO (section) got number) c (grave number) O Name of Sexton or Person in Char of Premises 1�/‘ a 0 Z (please rint) W ic Signature Title (Ll�N°�� DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of t . . ' delivered on { , 20 i9 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#