Cook, Serenity itSOy
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section U Burial - Transit Permit
Name First Middle Last Sex
Serenity Cook Female
Date of Death Age If Veteran of U.S.Armed Forces,
July 8, 2023 2lo wts ?sNc)no,1 War or Dates
ce of Death Hospital, Institution or &o ns Cots
w City)Town or Village C�r�S S�,S Street Address 15$ ���� , Nrt
O Manner of Death, Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
w Medical Certifier Name Title
o Kc,sr ^c C1 C r\'- pN P
Address ) 00 ?irk S'''17,.0.Q4- \ C\e vn S F- 1\ S \ }'r1 i 2 go 1
h Certificate Filed c- District Number Register Number
Town or Village G`2.( 5 t� ‹ "S D�'G� 3
❑Burial Date .4_ \1Z ) 23 Cemetery or Crematory 1�``
y
Address
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line J\e.�J CCe G Tv/'
❑Entombment
Cremation Zl Qv,G1CAn , Q,Ae e ins\,.\A c-- agO y
Date Place Removed
z El
Removal and/or Held
and/or Address
E Hold
0 Date Point of
q, ❑Transportation Shipment
.: !! by Common Destination
L7 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
a. Permission is hereb granted to dispose of the human remain described above as indicated.
Date Issued 1/t 1l ZC- 3Registrar of Vital Statistics t�
(signer aEu�)
District Number ba:0\ Place Cl1 I( S ,1\5 10/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 7 I►31 Z3 Place of Disposition fJU_ '0--,
W (address)
CO
TE (section) of number) (grave number)
Name of Sexton or Person in a e of Premises r•stt� S,k,,,it
print)
Signature �� Title (pleas U/lftZ✓1
(over!
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) I 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#