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Burgess, Josephine K UNEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Josephine K.Burgess Female Date of Death Age If Veteran of U.S.Armed Forces, 05/25/2023 67 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 74 Surrey Field Drive,Queensbury Town, New York 12804 W Manner of Death g � �Natural Cause Accident �Homicide Suicide Undetermined ❑Pendin W Circumstances Investigation U W Medical Certifier Name Title Lynn Keil PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 81 Burial Date Cemetery,Crematory or Facility Name 05/27/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held H Hold Address 0 Q. Date Point of (I)ETransportation Shipment p by Common Carrier Destination Date Cemetery Address Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 5 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/26/2023 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition .-130 I 11 Place of Disposition Ts-V 4----- Ill (address) W CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises pr L it ( ease print) W Z9 Title (IC Signature DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt jHuman remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#