Mazur, Joan Marilyn S ` `. 4 s----)
NEW YORK STATE DEPARTMENT OF HEALTH --- Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Joan Marilyn Mazur Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/13/2023 90 Years War or Dates
1.._ Place of Death Hospital,Institution or
WCity,Town or Village Wilton Town Street Address 21 Suffolk Lane,Wilton Town, New York 12831
p Manner of Death El Natural Cause Accident n Homicide nSuicide Undetermined (]Pending
UCircumstances '' ''Investigation
WW Medical Certifier Name Title
Christopher Messitt DO
Address
4 Congress Place,Saratoga Springs,New York 12866
Death Certificate Filed Town Of Wilton District Number Register Number
City,Town or Village 4569 4
Burial
9 Cemetery,Crematory or Facility Name
01/17/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
Q. Date Point of
Cl)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
IllReinterment 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 or to Whom
1— Remains are Shipped,If Other than Above
g Address
OC
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/17/2023 Registrar of Vital Statistics Susan Baldwin((lectronicall:y 49n4
(signature)
District Number 4569 Place Town Of Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition I I IC j,, Place of Disposition k
11.1
ki4C------,
—
2 (address)
W
CC CC (section) itiT-..,
(lot numb (grave number)
0 Name of Sexton or Person in Charge of Premises ti`�Zse print) /,
W Signature Title 11 Avg
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
U ! F7 6'34
1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#