Bly, Victoria Lynn # zyc
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Victoria Lynn Bly ! Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/13/2022 64 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
LU
p Manner of Death EINatural CauseIllAccident Homicide El Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
O Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 163
Burial Date Cemetery,Crematory or Facility Name
03/17/2022 Pine View Crematory
Entombment Address
[]Cremation Queensbury Town,New York
Donation
[]Removal Date Place Removed
and/or and/or Held
N Hold Address
O
Date Point of
N[]Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
[]Disinterment
Date Cemetery Address
[]Reinterment
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
i— Remains are Shipped,If Other than Above
Address
CC
W
Ct' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/16/2022 Registrar of Vital Statistics Megan Wolin(ECectronicaTySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
Z Date of Disposition 3 j gin_ Place of Disposition
W
(address)
W
N
O (section) (lot number) )r_� l� (grave number)
Name of Sexton or Person in Charge of emises d '�
Z (plea a print/Signature Title 4 M Vi
DOH-1555(o7/18)p t of 2
0'c 189 4-
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#