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Russell, Evon Fay NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Evon Fay Russell Female Date of Death Age If Veteran of U.S.Armed Forces, 10/07/2023 69 Years War or Dates F. Place of Death Hospital,Institution or WCity,Town or Village Chester Town Warren Street Address 7774 New York State 9 Route,Chester Town Warren,New York 12860 'p Manner of Death �NaturalCause Accident IEI Homicide Suicide ❑Undetermined n Pending Circumstances Investigation W Medical Certifier Name Title 0 Lynn Keil PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Chester District Number Register Number City,Town or Village 5652 17 Burial Date Cemetery,Crematory or Facility Name 10/10/2023 Pine View Crematorium _Entombment Address ©Cremation Queensbury Town,New York Donation 0Z Removal Date Place Removed and/or and/or Held F Hold Address N 0 Date Point of ()❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom — Remains are Shipped,If Other than Above S Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/09/2023 Registrar of Vital Statistics Minify Conway(ECectronicaltySigned) (signature) District Number 5652 Place Town Of Chester I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition /Q-JO- 62Zoz 3 Place of Disposition „j e 2 (address) W (section) of (grave number) a Name of Sexton or Person in Charge of Premise �li�`/1(1.JJ (JGC� (please print) Signature � 1 Title 0C2S��� 1 DOH-1555{07/18)p 1 of 2 - ; I Public Health Law Sec. 4145(2b) ' ° ,.r Receipt r Human remains of f delivered on , 20 Pine View Cemetery Representing the funeral home named,on bktria,l,p9mit Official Funeral Directors Reg.or License#