Stearns, Carol A • , ...., -4:11...
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Carol A.Stearns Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/05/2022 68 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Lake Luzerne Town Street Address 283 Galley Hill Road, Lake Luzerne Town, New York 12846
p Manner of Death 0 Natural Cause Accident []Homicide []Suicide []Undetermined ❑Pending
V1 'Circumstances Investigation
ILI 0 Medical Certifier Name Title
John Stoutenburg MD
Address
100 Park St,Glens Falls, New York 12801
Death Certificate Filed Town Of Lake Luzerne District Number Register Number
City,Town or Village 5656 22
Burial Date Cemetery,Crematory or Facility Name
09/07/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZRemoval Date Place Removed
and/or and/or Held
} Hold Address
N
0
O. Date Point of
(n OTransportation
p by Common Shipment
Carrier Destination
Date Cemetery Address•
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
11' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/06/2022 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed)
(signature)
District Number 5656 Place Town Of Lake Luzerne
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IN )
Z Date of Disposition qJ'] /7Z Place of Disposition �,�1
2 address/
W
U)
LC (section) A,,,-(lot number) (grave number)
0Name of Sexton or Person in Charge of Pre ' es L_. Ssi,1t LT
Z �,� (4ase print)�^
ILJ Signature L/ Title C (L4rholl
DOH-1555(07/18)pi of 2
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#