Mitchell, Bonnie J - F 1 )
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Bonnie J.Mitchell Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/05/2022 76 Years War or Dates
F— Place of Death Hospital,Institution or
W City,Town or Village Lake Luzerne Town Street Address 8 Lady Slipper Lane,Lake Luzerne Town, New York 12846
Q▪ Manner of Death E1 I I Natural Cause Accident Homicide Suicide Undetermined ❑Pending
O Circumstances Investigation
QMedical Certifier Name Title
Tammy Wheeler PA
Address
11 Hampstead Place 103,Saratoga Springs,New York 12866
Death Certificate Filed Town Of Lake Luzerne District Number Register Number
City,Town or Village 5656 26
Burial.]
Date Cemetery,Crematory or Facility Name
10/07/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
O. Date Point of
U)❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
El 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
a Address
IX
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/07/2022 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—
WDate of Disposition /C-7i 7y Place of Disposition s 0)e �,p� Cf,e-met./p 1,p
2 (address) J
W
CC N (section) (lot number (grave number)
O Name of Sexton or Person in Char of Pr mi /�//�'ID rJ �J Ud
Z (please print)
W Signature Q ATitle o f o��-t0,5---
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
I
I
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#