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Weller, Betty Jean NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Betty Jean Weller Female Date of Death Age If Veteran of U.S.Armed Forces, 02/24/2022 95 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town, New York 12803 W Manner of Death © Natural Cause ❑Accident I=1 Homicide El Suicide 111 Undetermined Pending Circumstances Investigation W Medical Certifier Name Title CI Madison Zuis NP Address 9-Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 12 Burial Date Cemetery,Crematory or Facility Name 02/25/2022 Pine View Crematory ❑Entombment Address QCremation Queensbury Town,New York ElDonation Z Removal Date Place Removed and/or and/or Held N Hold Address 0 0- Date- Point of (A LiTransportation tit p by Common Shipment Carrier Destination El Disinterment Date Cemetery Address Reinterment 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 1— Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. • Date Issued 02/25/2022 Registrar of Vital Statistics Leeann 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: Z Date of Disposition 21Z$(Z,Z Place of Disposition ,.u,`J` d(.�-•� address) W CC (section) (lot numbed J�(grave number) Name of Sexton or Person in Charge of Premises G ' Pa /fr°i Z (please rint) W Signature Title 0161/141192 DOH-1555(07/18)p t of 2 0IF 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#