Bolster, Ernest NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ernest Stewart Bolster Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 2, 2012 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
1.
0 Circumstances Investigation
a; Medical Certifier Name Title
Devon Bock, Dr.
Address
17 Baywood Dr. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village `�(o 0/ /O Z
{v
®Burial Date Cemetery or Crematory
March 6, 2012 Pine View Cemetery
❑Entombment Address
='4.=❑Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
M.❑
Removal and/or Held
and/or Address
Hold
gt Date Point of
C ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
III Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is here y granted to dispose of the human remains defcciy ab a as ' is ted.
Date Issued D /o / /2—Registrar of Vital Statistics
(signature)
District Number 5 .' Place ''/ ,.'' 7;:f/5, /V-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/06/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Mohawk 73 1
(section) (lot number) (grave number)
Name of Sexton or Personfl harge of Premises Michael Denier
(please print)
Signature Title Superintendent
(over)
DOH-1555 (02/2004)