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Fox, Elizabeth Anne iv R ,y # NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permitt Bureau of Vital Records Name First Middle Last Sex Elizabeth Anne Fox Female Date of Death Age If Veteran of U.S.Armed Forces, 12/09/2023 63 Years War or Dates F, Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 441 Lockhart Mountain Road Unit 1,Queensbury Town,New York 12845 p Manner of Death ❑^ Natural Cause illAccident ❑Homicide ESuicide Undetermined ❑Pending W V Circumstances Investigation W Medical Certifier Name Title G Suzanne Bergin DO Address 9 Carey Road,Queensbury Town, New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number ,y,Town or Village 5657 186 Burial Date Cemetery,Crematory or Facility Name 12/11/2023 Pine View Crematory Entombment — Address ©Cremation Queensbury Town,New York EiDonation 0❑Removal Date Place Removed and/or and/or Held f- Hold Address U) 0 a Date Point of U) Transportation 0 by Common Shipment Carrier Destination EDisinterment Date Cemetery Address E Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address CC W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/11/2023 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition izlii Place of Disposition 1 ` %d`e`� (I2.E,YArylzIUr.--. 2 (address) W fr (section) /lot number (grave number) O Name of Sexton or Person in Charge of P mises d•01„.,ase , fl z ease print Z W Signature j Title f ✓► Oa '7 DOH-1555(07/18)p 1 of 2 3 •_?,.7 7 4Public 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#