Celmer, Jayne 0 A ZSc
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jayne Celmer Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/16/2022 79 Years War or Dates
i_ Place of Death Hospital,Institution or
WCity,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
p Manner of Death ❑X Natural Cause Accident 0Homicide 1Duicide FlUndetermined ElPending
W Circumstances Investigation
WMedical Certifier Name Title
G Shardul Koppar DO
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed Town Of Granville District Number Register Number
City,Town or Village 5756 16
Burial Date Cemetery,Crematory or Facility Name
MIMI 03/21/2022 Pine View Crematory --
Entombment
Address
Cremation Queensbury Town,New York
Donation
Z ElRemoval Date Place Removed
and/or and/or Held
F— Hold Address
N
0
Date Point of
CA❑Transportation Shipment
Q by Common
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
f" 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 03/21/2022 Registrar of Vital Statistics Jenny Linda M Martelle(Electronically Signed)
(signature)
District Number 5756 Place Town Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I.-
• Date of Disposition 3jrt lit Place of Disposition 44...,(4 24—
W - (address
W
N (section) (1 number) (grave number)
CC
O Name of Sexton or Person in Charge of Prem. es (.3 L. n ets'"
� (please p�tJ
W Signature Title
DOH-1555(07/t8)p 1 of 2
0 ?. -;904
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#