Petersante, Kathleen M NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kathleen M. Petersante Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/26/2022 67 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Lake Luzerne Town Street Address 192 Old Stage Road, Lake Luzerne Town,New York 12846
UJ Manner of Death ❑X Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
0 Circumstances Investigation
W Medical Certifier Name Title
CI Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Lake Luzerne District Number Register Number
City,Town or Village 5656 20
Burial Date Cemetery,Crematory or Facility Name
08/27/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town, New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
d Date Point of
Cl)❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
❑Reinterment
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
I— Remains are Shipped,If Other than Above
5 Address
Cr
LU
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/27/2022 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:
I—
Z Date of Disposition g.�a.,a,deyy Place of Disposition p1f1v Vri‘.) GGic)(Y
2 (address)
W
NCC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises c,. tt P1 _4' Sf rti$
Z (please print)
W Signature Title fired%aid
DOH-1555(07/18)p 1 of 2
01619g
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
,i'e View Cemery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#