Lemery, Kathleen Ann 3 ,,-,
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kathleen Ann Lemery Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/07/2022 65 Years War or Dates
F.. Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 18 Nolan Road,Moreau Town,New York 12803
p Manner of Death ❑X Natural Cause Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending
0 Circumstances Investigation
W Medical Certifier Name Title
0
Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 9
ElBurial Date Cemetery,Crematory or Facility Name
02/10/2022 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
m Hold Address
0
O. 1-1 Date Point of
lb Li Transportation
al by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
•E Address
CC
W
O.. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/09/2022 Registrar of Vital Statistics LeeannMcca6e(Electronicaty5irned)
(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:
I—
W Date of Disposition 0-7-0}). Place of Disposition �Jii, 0t14) Cir�rbQkcy
2 (address)
W
Q (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises D<km c,,i' Si/rk,S
z (please print)
W Signature Title C.re.+'t 4/c.F
DOH-1555(07/18)p i 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#