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Boyack, Dorothy Carolyn
V\,, 4 713 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dorothy Carolyn Boyack Female Date of Death Age If Veteran of U.S.Armed Forces, 08/31/2023 81 Years War or Dates H Place of Death Hospital,Institution or rZ City,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803 p Manner of Death El Natural Cause IllAccident Homicide []Suicide Undetermined ❑Pending W 0Circumstances Investigation 111 G Medical Certifier Name Title Madison Zuis NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 47 ElBurial Date Cemetery,Crematory or Facility Name 09/05/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York ▪Donation Z Removal Date Place Removed and/or and/or Held H Hold Address U) O O. Date Point of U)0Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address 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 l._ Remains are Shipped,If Other than Above 5 Address C LU O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/04/2023 Registrar of Vital Statistics Brenda Rutter(Electronically Signed) (signature) District Number 4562 Place Town Of Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: //�� Date of Disposition 9I to 1/3 Place of Disposition 4JI , `"`�T� W (addrlis7) WICC (grave number) (section) of number) 8 Name of Sexton or Person in Charg2 ' es f P e lif (plea LU III 6,61941971 LU Signature Title DOH-1555 07/18)p 1 of 2 rF. f s. Public Health Law Sec. 4145(2b) Receipt Human remains of E delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#