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Coffin, Cheryl Ann t. D3 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Cheryl Ann Coffin Female Date of Death Age If Veteran of U.S.Armed Forces, 10/03/2023 56 Years War or Dates i_ Place of Death Hospital,Institution or Z- City,Town or Village Greenwich Town Street Address 43 Galesville Road, Greenwich Town, New York 12834 pManner of Death El Natural Cause EAccident Homicide Suicide nUndetermined Pending 111 0 Circumstances Investigation W Medical Certifier Name Title 0 Joanna Robben PA Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed Town Of Greenwich District Number Register Number City,Town or Village 5757 18 RBurial Date Cemetery,Crematory or Facility Name 10/05/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held f- Hold Address CO 0 CI- Date Point of Cl)❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment 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 H Remains are Shipped,If Other than Above 5 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/05/2023 Registrar of Vital Statistics Deborah Tjarks(ECectronica(CySigned) (signature) District Number 5757 Place Town Of Greenwich I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition JG-7 .3 t Place of Disposition l :.J+e ✓:e4 ' C r-(414-44-1 W (address) W Cl)CC (section) (lot number) (grave number) gipoName of Sexton or Person in Charge of emise ��F{ ��f � el Z (please print/ W Signature f Title 1 ti S— DOH-1555(07/18)p 1 of 2 666 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# ', ;1 „.a ,