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Quay, Kimberly Karen NEW YORK STATE DEPARTMENT OF HEALTH # 11D Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kimberly Karen Quay Female Date of Death Age If Veteran of U.S.Armed Forces, 01/28/2024 58 Years War or Dates t Place of Death Hospital,Institution or WCity,Town or Village Lake George Town Street Address 21 Newton Street, Lake George Town, New York 12845 ILI C.)p Manner of Death El NaturalCause Accident Homicide Suicide Undetermined ❑Pending Circumstances Investigation G Medical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed Town Of Lake George District Number Register Number City,Town or Village 5651 2 Burial Date Cemetery,Crematory or Facility Name 02/01/2024 Pine View Crematory Entombment Address ©Cremation Queensbury,New York Donation goRemoval Date Place Removed and/or and/or Held H Hold Address 0 O. Date Point of U) Transportation p by Common Shipment Carrier Destination oDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above a Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/31/2024 Registrar of Vital Statistics Patricia R9Kc?(inney-Schuster(ECectronicaCCy Signed) (signature) District Number 5651 Place Town Of Lake George I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 212.121 Place of Disposition -r C/LE:� C' A1�4Tt 4 2 (address) W Q (section) (lot number) (grave number) 8 Name of Sexton or Person in Charge of Premises /1'.' - �H z pase print) W Signature Title �� �4 Tat_ DOH-1555(o7h8)p 1 of 2 1 ` 1 Public Health Law Sec. 4145(2b) 1 Receipt 1 Human remains of delivered on , 20 1 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#.