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Bimbaum, Gerald I 5— NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Gerald A.Bimbaum Male Date of Death Age If Veteran of U.S.Armed Forces, 12/30/2017 69 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Suzanne Blood MD Address 152 Sherman Ave,Queensbury Town,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Queensbury 5657 167 ❑Burial Date Cemetery or Crematory 01/02/2018 Pine View Crematory gip=❑Entombment Address w; Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address Date❑ CemeteryAddress Renterment 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 Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/01/2018 Registrar of Vital Statistics Caroline?(Bar6er(E(ectronicallySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 1I 5 lig Place of Disposition `,MJ,l �.,r.- (address) (section) A (lot number (grave number) Name of Sexton or Person in Charge of Premises ke- (leease print) Signature ( Title (over) DOH-1555(02/2004)