Martinez, Awilda I
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Awilda Martinez Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/15/2024 75 Years War or Dates
f.. Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death 1-1 Natural Cause Accident []Homicide Suicide Undetermined []Pending
111
Circumstances I 'Investigation
W Medical Certifier Name Title
O Nicole Humiston NP
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 20
[ ]Burial Date Cemetery,Crematory or Facility Name
03/15/2024 Pine View Crematory
[]Entombment —
Address
[]Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Field
H Hold Address
N
0
d Date Point of
(/)[]Transportation
p by Common __-- Shipment
Carrier Destination
Date Cemetery Address
[]Disinterment
Date Cemetery Address
[]Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
.- Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/15/2024 Registrar of Vital Statistics Aimee LMahoney(Llectronicall:y,Sign4
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WI -Pi—
Date of Disposition 3-He- v!M Place of Disposition 4-i 4/e,,,, F 'i ',-'e
2 (address)
W
U)
CC (section) ]� (lot number) (grave number)
O Name of Sexton or Person in Char of Pre ise r / � r�� ���
Z Signature `' — — (Please print)
W __ Title ���S� f
DOH-1555(07/18)p 1 of 2
Public 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#