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Harrington, Carol Faye 1...-F' # g 1--i NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Carol Faye Harrington Female Date of Death Age If Veteran of U.S.Armed Forces, 10/06/2023 80 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Fort Ann Town Street Address 89 Buttermilk Falls Road,Fort Ann Town, New York 12827 p Manner of Death ❑^ Natural Cause nAccident [ ]Homicide ESuicide ElUndetermined ❑Pending UCircumstances Investigation 0 Medical Certifier Name Title Michael Adams MD Address 1448 Route 9,Fort Edward Town,New York 12828 Death Certificate Filed Town Of Fort Ann District Number Register Number City,Town or Village 5754 12 Burial Date Cemetery,Crematory or Facility Name 10/11/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Z❑Removal Date Place Removed and/or and/or Held ~ Hold Address CO 0 Q. Date Point of Cl)❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address nDisinterment Date Cemetery Address E Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above Address CC a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/11/2023 Registrar of Vital Statistics _Miranda.7ferring law(ElectronicalySigned) (signature) District Number 5754 Place Town Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Il— W Date of Disposition 101131 i!3 Place of Disposition Fr it,.;j&../ ('Qlirl4 AT-4H)< 2 (address) W CC CC (section) (lot number) (grave number) aName of Sexton or Person in Charge of Premises °'> Z /._..7.,f (p ase print) /W Signature Title ( 111W DOH-1555(018)p 1 of 2 01, rx36 Public Health Law Sec. 4145(2b) Receipt • Human remains of delivered on "' , 20 Pine View Cemetery Representing the funeral home named on buriermit Official Funeral Directors Reg.or License# /' �'