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Gates, Dawn Marie v4111) l Ll NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dawn Marie Gates Female Date of Death Age If Veteran of U.S.Armed Forces, 02/03/2023 53 Years War or Dates ZZ Place of Death Hospital,Institution or LIU City,Town or Village Fort Edward Village Street Address 61 Seminary Street, Fort Edward Village, New York 12828 p Manner of Death El Natural Cause Accident 0 Homicide ESuicide Undetermined 171Pending W U Circumstances v=1Investigation LU Medical Certifier Name Title Robert Lemieux Coroner Address 415 Lower Main Street, Hudson Falls Village,New York 12839 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 19 Burial Date Cemetery,Crematory or Facility Name 02/13/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York DDonation OZ❑Removal Date Place Removed - and/or and/or Held N Hold Address 0 a. Date Point of (/)❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward, New York 12828 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above M Address CC Ill O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/07/2023 Registrar of Vital Statistics Aimee L 512ahoney(ECectronicarcySigned) (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: I- ,� Z Date of Disposition Place of Disposition Y °c �l jam,J ��/��y1sv� w /13-Z©0 p 2 (addre s) W CC (section) "(lot number)/ (grave number) 0 Name of Sexton or Person in har of P emises tov/Gwvl (g�rn-�t — Z (please print) W 6 Signature g Title ilC�v,�t— ce^rro,._,...-A4/— DOH-1555(07/18)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#