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Gardner, Doris Mabel @ # fc-0 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Doris Mabel Gardner Female Date of Death Age If Veteran of U.S.Armed Forces, 10/19/2023 99 Years War or Dates 1.., Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803 111 U0Manner of Death ❑l Natural Cause Accident Homicide Suicide Undetermined nPending Circumstances II ''Investigation W Medical Certifier Name Title 0 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 59 ElBurial Date Cemetery,Crematory or Facility Name 10/23/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation ZZ Removal Date Place Removed and/or and/or Held ~ Hold Address N 0 0. Date Point of Cl)ElTransportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address C 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 1— Remains are Shipped,If Other than Above Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/21/2023 Registrar of Vital Statistics Brenora.7futterglectronicallySignea9 (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: F Z Date of Disposition 10173)'t3 Place of Disposition fr,4 L ti '6 MAIVALIANN 2 (address) uJ CO CC (section) (Air, (lot number:Jl�>ti (grave number) 0Name of Sexton or Person in Charge of Premises �w Z sse print) ` W Signature a Title `OOnitirlii DOH-1555(07/t8)p i of 2 J17 99 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named one burial permit Official Funeral Directors Reg.or License#