Furio, Helene M tt
NEWYORKSTATEDEPARTMENTOFHEALTH `. �F _ 'IN
Bureau of Vital Records Burial Transit Permit
Name First Middle Last Sex
Helene M. Furio Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/11/2022 74 Years War or Dates
h Place of Death Hospital,Institution or
Z City,Town or Village Lake Luzerne Town Street Address 17 Zimmer Drive, Lake Luzerne Town, New York 12846
w Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
✓ Circumstances Investigation
W Medical Certifier Name Title
O Edward Liebers MD
Address
3 Care Lane 300,Saratoga Springs,New York 12866
Death Certificate Filed Town Of Lake Luzerne District Number Register Number
City,Town or Village 5656 29
Burial Date Cemetery,Crematory or Facility Name
12/12/2022 Pine View Crematory
Entombment Address
I1Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
d Date Point of
CO IllTransportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
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
H. Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/12/2022 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 w rmit on:
/9
ZLIU Date of Disposition 121'31 7Z Place of Disposition �I,,V� l J---
2 (address)
W
CC 0 (section) (lot number) (grave number)
G Name of Sexton or Person in Charge o remises
0 lnk L-
Z please print)
W _ Title Atr MW Wil
Signature
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) r
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#