Burt, Cindy Jean @I'
NEW YORK STATE DEPARTMENT OF HEALTH .��z 1
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cindy Jean Burt Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/07/2022 62 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 1 Myron Road,Moreau Town,New York 12803
p Manner of Death Natural Cause []Accident III Homicide Suicide InUndetermined yi Pending
W
I—I
U Circumstances Investigation
W Medical Certifier Name Title
O Anthony Perniciaro Coroner
Address
6012 County Farm Road,Ballston Spa Village,New York 12020
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 51
Burial Date Cemetery,Crematory or Facility Name
® 09/10/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
O. Date Point of
Cl)OTransportation Shipment
p by Common
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
H Remains are Shipped,If Other than Above
i Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/09/2022 Registrar of Vital Statistics Leeann McCabe(Electronically Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H ,...1731.Z Date of Disposition q laIZZ Place of Disposition _ +++
2 (address)
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CC (section/ (lot number) (grave number)
Name of Sexton or Person 2geofPremissh c' , 4\. .,t
Z /p ease print)
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W Signature Title W �
DOH-1555(o7/18)pi of 2
Public Health Law Sec. 4145(2b)
Receipt
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Human remains of ` ' "�' ''delivered on ` , 20 '- —
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Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License# ` r ` 7 I'`