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Samuelson, Jared Nathaniel NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jared Nathaniel Samuelson Male Date of Death Age If Veteran of U.S.Armed Forces, 01/29/2020 128 Years War or Dates �.. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital LU p Manner of Death Natural Cause Accident Ej Homicide Suicide Undetermined ©Pending 0 Circumstances Investigation WLLI Medical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town, New York 12845 Death Certificate Filed District Number Register Number City,Town or Villa a Glens Falls 5601 53 Burial Date Cemetery,Crematory or Facility Name 02/03/2020 Pine View Crematory Entombment Address RCremation Queensbury Town,New York Donation 0 Removal Date Place Removed and/or and/or Held F- Hold Address N O a Date Point of N ❑Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address IM W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/03/2020 Registrar of Vital Statistics 9�gbert,4ndrew Curtis(6lectronicallySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 1/3 J Z0 Place of Disposition W 2 (address) W N M /section/ (tot num /grave number/ 0 Name of Sexton or Person in Charge of Premises 483- ` 1 Z please print/ W Signature �� Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) - . 13, • l'}- Receipt Human remains of s delivered on , 20 Pine View Cemetery Representing the .f.0 etal home named on burial perm Official Funeral Directors Reg.or License# 17