Lange, Olean Esther L IF 33 LI
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Olean Esther Lange Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/19/2022 69 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 141 White Birch Estates 141,Moreau Town,New York 12828
a Manner of Death 0 Natural Cause Accident ID Homicide Suicide Undetermined ❑Pending
0 Circumstances Investigation
CW Medical Certifier Name Title
David DeCelle Coroner
Address
40 McMaster Street,Ballston Spa,New York 12020
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 19
Burial Date Cemetery,Crematory or Facility Name
04/20/2022 Pine View Crematory
Entombment Address
,-''ICremation Queensbury Town,New York
riDonation
Z Date Place Removed
0 0 Removal
H and/or and/or Held
N Hold Address
0
4 Date Point of
CO❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
E— Remains are Shipped,If Other than Above
2 Address
xis.#.
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/20/2022 Registrar of Vital Statistics Leeann 9Kc ca6e(Electronically Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1-
Z Date of Disposition LI 14 I ZZ Place of Disposition t7)9r�
T (a dress)
w
CO (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises / Nt ^r1�t��
Z , ilease print/
W Signature Title
DOH-1555(07/18)p t of 2
U I F 4�.
,.1. L :?'
Public Health Law Sec. 4145(2b)
Receipt
1
1 Human remains of delivered on , 20
1
1
1
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# -