Greene, Andrea I a
NEW YORK STATE DEPARTMENT OF HEALTH .
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Andrea Greene Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/23/2022 66 Years War or Dates
F Place of Death Hospital,Institution or
ZCli City,Town or Village Queensbury Town Street Address 143 Elmhurst Drive,Queensbury Town,New York 12804
Manner of Death El Natural Cause ❑Accident El Homicide ESuicide Undetermined ri Pending
W
0 Circumstances Investigation
Q Medical Certifier Name Title
Paul Bachman MD
Address
9 Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 123
Burial Date Cemetery,Crematory or Facility Name
08/25/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
pCDHold Address
0
O Date Point of
tf)1=1 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
... Remains are Shipped,If Other than Above
MIM
"IE Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/24/2022 Registrar of Vital Statistics Caroline.?ii(Iegarc Barber(E(ectronica(TySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition Place of Disposition p; v:.f,w C12.m,jtc',r
1 (addtess)
W
CA
Ir (section) (lot number) (grave number)
gName of Sexton or Person in Charge of Premises J e rime.- .59t:;r-CS
Z (Tease print)
W Signature Title GrGmol4or
DOH-1555(07/18)p 1 of 2
I
A.
Public Health Law Sec. 4145(2b)
IReceipt
1
1
1 Human remains of delivered on , 20
1
1
1
1
i Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#