Defoe, Shirley Ann L
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shirley Ann DeFoe Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/27/2023 89 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death Ei Natural Cause nAccident ❑Homicide El Suicide Undetermined ❑Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 113
Burial Date Cemetery,Crematory or Facility Name
02/28/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
4. Date Point of
U)nTransportation
p by Common Shipment
Carrier Destination
ri
Disinterment
Date Cemetery Address
Date Cemetery Address
E 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
i.— Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/28/2023 Registrar of Vital Statistics Megan North glectronicall:y Signer
(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:
Z Date of Disposition 173 Place of Disposition
2 (address)
W
NCC (section) /2 (lot number) (grave number)
�(fL �
• Name of Sexton or Person in Charge of P ises / !�
(p ase print)
Z
W Signature Title /' OQ
DOH-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b)
I Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#