Booska, Beverly P 030C
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Beverly P• Middle Last Sex
F
Booska
Date of Death Age If Veteran of U.S. Armed Forces,
04/05/2022 83 War or Dates
Place of Death Hospital, Institution or OWarren Rd
Hartford
City, Town or Village Street Address
Manner of Death ®Natural Cause ❑ Accident 0 Homicide ❑ Suicide FlUpdetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Allen Eisemann MD
Address 160 Allen St . , Rutland VT 05701
Death Certificate Filed District Number Register Number
City, Town or Village Hartford
❑Burial Date Cemetery or Crematory
04/08/2022 Pine View CEematory
❑Entombment Address
E cremation 21 Quaker Rd, Queensbury , NY 12804
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
Q Reinterment
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01079
Address 82 Broadway , Fort Edward , NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h eby granted to dispose of the human remai s escribed a i� ts Indic e
Date Issued \_-
2Z Registrar of Vital Statistics Q,tuc' 'L1l Ln yvV�-
(sign ture)
District Number 91 Stfk Place ---i--OLv►, 0 Q- r( i vid
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 4-g we_ Place of Disposition ? ,'e (`;ea.4.3 Cr css'IA
(address)
(section) (lot number) i (grave number)
Name of Sexton or Person in harg remises ] AK� �� �10r�Dcr
(ple se print)
Signature Title 4e-e-- C
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b)
Receipt
Human remains of 'delivered on , 20 •
Pine View Cemetery Representing the funeral home named on bur permit
Official Funeral Directors Reg.or License# - •'