Converse, Deborah Lynn LF
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Deborah Lynn Converse Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/15/2022 68 Years War or Dates
�,. Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 4 Cherokee Lane,Queensbury Town, New York 12804
O Manner of Death n Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
W
V I Circumstances Investigation
W Medical Certifier Name Title
G Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Queensbury District Number Register Number
y,Town or Village 5657 179
Burial Date Cemetery,Crematory or Facility Name
11/18/2022 Pine View Crematory
Address
ECremation Queensbury Town,New York
Donation
• Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
Cl)nTransportation Shipment
• by Common
Carrier Destination
„>arrtu.a.
Date Cemetery Address
Disinterment
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 orb Whom
F. Remains are Shipped,If Other than Above
2 Address
CC
W
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/18/2022 Registrar of Vital Statistics Carotinexkkgard Bar6er(Ekctronicall:y Signed)
(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:
� )
W Date of Disposition // J9 Zc�Zz Place of Disposition � iJP h''1 ee)
(address)
W
CC (section) (lot number) (grave number)
O Name of Sexton or Person in Charge QQf Premises ellvine ' LIA,L'C'
(please print)
W Signature le/7 ` 4 Title Ly- 'C—
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on II- i g , 20_�
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#