Doty, Beverly Ann ..._..... .
C431
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Female
Beverly Ann Doty
Date of Death Age If Veteran of U.S.Armed Forces,
12/30/2022 82 Years War or Dates
i_ Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death �Natural Cause Accident Homicide Suicide Undetermined El Pending
C.) Circumstances II ''Investigation
W Medical Certifier Name Title
CI Bo Li MD
Address
100 100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 668
Burial Date Cemetery,Crematory or Facility Name
01/09/2023 Pine View Crematory
DEntombment Address
Cremation Queensbury Town,New York
Donation
Date Place Removed
• Removal and/or Held
I- and/or
t)
Hold Address
O Date Point of
Cl)❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
0 Reinterment
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
1— Remains are Shipped,If Other than Above
N Address
CC
W
iL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/03/2023 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:
~ Place of Disposition ' :1'L 4----,-
W Date of Disposition )�� l3 (address)
W
U) (section) dot numbeS—v\A (grave number)
CC
O Name of Sexton or Person in Char remises A
"�$)`' 11
Z (please print)
Z ,� Ce 11 rOZ
W Signature Title
DOH-1555(o7/18)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#-