Swan, Karen A ,ei -N, 1/ '07-
NEW YORK STATE DEPARTMENT OF HEALTH �- Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Karen A Sawn Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/16/2022 78 Years War or Dates
l— Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
p Manner of Death g Natural Cause Accident ❑Homicide Suicide Undetermined n Pending
Circumstances ' Investigation
V Title
W Medical Certifier Name
CI Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 578
Burial Date Cemetery,Crematory or Facility Name
11/19/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
F— Hold Address
CO
0
Date Point of
Cl)DTransportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
g Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
g
Date Issued
11/17/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(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: //L�
W~ Place of Disposition �,71�
Date of Disposition 1 IS 11 (a dress)
W number)
Co (section) (�number) (grave
CC (section)
0 Name of Sexton or Person in Charge of Premises (please p ntt)ot, a �
W Signature Title
DOH-1555(o7/t8)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#