West, Charlotte NEW YORK STATE DEPARTMENT OF HEALTH .(1_,F)
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charlotte West Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 19, 2023 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of DeathNatural Cause El Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
111
0 Circumstances Investigation
W Medical Certifier Name Title
Jennifer Bushant, M.D
1CO Itt4V _ al J, 1((s 411 /209/
Death Certificate Filed District Number INegister Number
City, Town or Village Glens Falls 560
❑Burial Date Cemetery or Crematory
September 21, 2023 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
Date Point of
d0 Transportation Shipment
0 by Common Destination
Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
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 remai escribed ove as indicated.
Date Issued g121�2.0?3 Registrar of Vital Statistics
4 tune)
District Number t Place Gben5 llS, Al
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 09/21/2023 Place of Disposition Quaker Road Queensbury,NY 12804
,. (address)
UI
EC (section) (tot umber) (grave number)
d Name of Sexton or Person in Charge of Premises 7^ L __.>.`ti
Z (please rint)
W Signature Title (17".1w
(over)
DOH-1555 (02/2004)
I
79Jr
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# - �-�t