Carey, Sally Ann .._@
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Sally Ann Carey Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/20/2023 82 Years War or Dates
l— Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death 17 Natural Cause Accident I I Homicide Suicide Undetermined ❑Pending
W
L.) Circumstances Investigation
W Medical Certifier Name Title
0 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 56
RBurial Date Cemetery,Crematory or facility Name
06/21/2023 Pine View Crematory
Entombment Address
nCremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
U)nTransportation Shipment
Q by Common
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
l— Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/21/2023 Registrar of Vital Statistics /limeeGalalzoneyg ctronicafSignerl)
(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:
~ Z-t�Z Date of Disposition (p I Z j 123 Place of Disposition ,�tt
2 (address)
W
Cl) (section) ` (lot number) (grave number)
0 / e L l4
Name of Sexton or Person in Charge of Pre .$es
Z (1 ase print)
W Signature Title 1-N•71M1iiix
DOH-1555(07/18)p 1 of 2
y _
0 / 0 ' ':6
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#