Bonitatibus, James NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
James Michael Bonitatibus Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/24/2019 73 Years War or Dates 1965-1969
Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
WW Manner of Death
�Natural Cause �Accident �Homicide �Suicide �Undetermined �Pending
V Circumstances Investigation
W Medical Certifier Name Title
John Quaresima MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 97
Burial Date Cemetery,Crematory or Facility Name
11/26/2019 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
z Removal Date Place Removed
and/or and/or Held
~ Hold Address
UN
O
I- Date Point of
N Transportation
(� by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
�— Remains are Shipped,If Other than Above
Address
Q
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/25/2019 Registrar of Vital Statistics Aimee Mahoney (Electronically,Signed)
/signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
Z Date of Disposition f Place of Disposition
W
(address)
W
N (section) (lot numbe lgra ve number/
4.4
0 Name of Sexton or Person in Charge of Premises I &f.t
z / ` /please print/
W Signature A // o Title
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) y f 013107
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#