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Elmer, Carol Lillian trCi7NEWYORKSTATEDEPARTMENTOFHEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Carol Lillian Elmer Female Date of Death Age If Veteran of U.S.Armed Forces, 01/26/2023 91 Years War or Dates • Place of Death Hospital,Institution or W• City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc D Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined El Pending ✓ Circumstances Investigation II,J© Medical Certifier Name Title Philip Gara MD Address 319 Broadway, Fort Edward Town,New York 12828 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 11 Burial Date Cemetery,Crematory or Facility Name 01/28/2023 Pine View Crematory Entombment — Address Cremation Queensbury,New York Donation Z Date Place Removed 0 0 Removal 1-: and/or and/or Held N Hold Address 0 O. Date Point of (/)OTransportation 5by Common Shipment Carrier Destination Disinterment Date Cemetery Address CIReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped,If Other than Above 2 Address CC III) 0. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/27/2023 Registrar of Vital Statistics Aimee G Mahoney(ECectronicalty Signed) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: / W Date of Disposition II3l LI 3 Place of Disposition �'-,,, Cam,i'173Yt, 2 (address) W 1 (section) A (lot number)a (grave number) 8 Name of Sexton or Person in Charge of Premisesil Z / 4oiease print) W Signature Lam` Title r��/bHI 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#