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Tousignant, Kerrie A
s4c1 3-9 NEW YORK STATE DEPARTMENT OF HEALTH ,�• 1 Permit Bureau of Vital Records Burial -Transit Name First Middle Last Sex Kerrie A Tousignant Female Date of Death Age If Veteran of U.S.Armed Forces, 11/14/2023 51 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Lake George Village Street Address 2 Cooper St 2,Lake George Village,New York 12845 p Manner of Death Z Natural Cause ❑Accident 0 Homicide 0 Suicide Undetermined riPending W Circumstances Investigation E Medical Certifier Name Title Thomas Portuese MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Village Of Lake George District Number Register Number City,Town or Village 5620 6 Burial . Date Cemetery,Crematory or Facility Name 11/20/2023 Pineview Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation 6❑Removal Date Place Removed and/or and/or Held F.asHold Address O 0.. Date Point of VI 0Transportation a by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above M Address C W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/16/2023 Registrar of Vital Statistics Julie Allen(Electronically Signed) /signature) District Number 5620 Place Village Of Lake George I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: II- Date of Disposition //-Z/ �(.a Zr'Z3 Place of Disposition le tl evo r'�i- 4 r3 ,g (address) W Cr (section) . /!ot umb r) (grave number) SName of Sexton or Person in Ch of P mi 'c`r/foio--� tqu b Z ff please print) W Signature ,j / Title ore.ra-te'r DOH-1555(07/18)p 1 of 2 A 7.7. t` Public Health Law Sec. 4145(2b) 1, Receipt Human remains of _ delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#