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Morency, Faith Kimberly ,. . # l6Z NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Faith Kimberly Morency Female Date of Death Age If Veteran of U.S.Armed Forces, 02/18/2022 58 Years War or Dates IN Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 65 Dixon Road,Queensbury Town, New York 12804 ILI Q Manner of Death ©Natural Cause ❑Accident ❑Homicide D Suicide u Undetermined El Pending W Circumstances Investigation U tlI Medical Certifier Name Title 0 Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 39 Burial Date Cemetery,Crematory or Facility Name 02/22/2022 Pine View Crematory ,.❑Entombment Address ElCremation Queensbury Town,New York ElDonation Z 1-1 Removal and/or Date Place Removed and/or Held H Hold Address N 0 Date Point of CO) Transportation Shipment p by Common Carrier Destination Date Cemetery Address ❑Disinterment 1=1Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above a Address Q W G' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/22/2022 Registrar of Vital Statistics Caroline 9f"iCdegardeBar6er(ECectronicallySigned) (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: ~ 21 I p ,�'V_ , , Z Date of Disposition 73 7Z Place of Disposition W ( dress/ g Ill Q (section) 1 (lojnumber) (grave number) Q Name of Sexton or Person in Charge/Premises !1 It 1 �N z (pi print) �}, iW Title ''�. 4. �� Signature DOH-1555(07/18)p 1 of 2 () 1:}8 0 8 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#