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Bush, Vivian Grace OLF A c40-13 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Vivian Grace Bush Female Date of Death Age If Veteran of U.S.Armed Forces, 08/20/2023 97 Years War or Dates F— Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc ui 'p Manner of Death ❑X Natural Cause []Accident El Homicide Suicide []Undetermined ❑Pending 0 ' 1Circumstances Investigation W Medical Certifier Name Title Carrie Miron PA 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 72 Burial Date Cemetery,Crematory or Facility Name 08/23/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation ZO❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 d Date Point of N Transportation p by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address ElReinterment Date Cemetery Address 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 1... Remains are Shipped,If Other than Above 5 Address CC W Ct' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/22/2023 Registrar of Vital Statistics .ilimeeL.falroney(E/ctronicall:y Signer° (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: H j Z Date of Disposition CI Nip Place of Disposition `/ oi-- W (address) Ui Cl)CC (section) /(lot number) (grave number) 0 Name of Sexton or Person in Charge of Premisftt Z (plea print) W Signature Title (Pre 1-1 DOH-1555(o7/18)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#