Cusick, Kathleen Elizabeth ,. • .
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kathleen Elizabeth Cusick Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/08/2022 83 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
ILI
a Manner of Death I1 Natural Cause Accident 0 Homicide 0Suicide Undetermined ri Pending
W U Circumstances Investigation
W Medical Certifier Name Title
a Matthew Loftus PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 461
Burial
R
Date Cemetery,Crematory or Facility Name
09/10/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
6❑Removal Date Place Removed
and/or and/or Held
F— Hold Address
CO
0
EL Date Point of
U)DTransportation
a 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-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
f— Remains are Shipped,If Other than Above
$• Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/09/2022 Registrar of Vital Statistics 911egan7Votin(ECectronica1TySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:rr 4"---
ZDate of Disposition 1ItZiI Place of Disposition 1t��-1L.-
ILI
2 (address)
W
CCCC (section) (loj�umber) (grave number)
S ,,Att
0 Name of Sexton or Person in Charge - miser �' v
Z (Pt se print)
W L/ Title M{4TOI�
Signature .'� Cr*
DOH-1555(07/18)p 1 of 2
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Public Health Law Sec. 4145(2b)
Receipt
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Human remains of , . • - ' '- '*4-delivered on . ' ' , 20 -
Pine View Cemetery Representing the funeral home named on.huria.1 permit
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Official Funeral Directors Reg. or License# ;, '