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Carruthers, George Lawrence ,'1-3 N EW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex George Lawrence Carruthers Male Date of Death Age If Veteran of U.S.Armed Forces, 05/16/2020 78 Years War or Dates 1963-1965 Place of Death Hospital,Institution or WCity,Town or Village Bolton Town Street Address 57 Lake Winds Road, Bolton Town, New York 12824 0 Mannerof Death © Natural Cause Accident �Homicide �Suicide �Undetermined ❑Pending UCircumstances Investigation © Medical Certifier Name Title Robert Love MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Bolton Landing 5650 4 Burial Date Cemetery,Crematory or Facility Name 05/19/2020 Pine View Crematory Entombment Address MCremation Queensbury Town,New York ❑Donation 0 F1 Removal Date Place Removed and/or and/or Held N Hold Address Q IL t(0) Transportation Date Point of Q 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-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 1 W' CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/18/2020 Registrar of Vital Statistics Jodi G Connally(Electronically Signed /signature/ District Number 5650 Place Bolton Landing, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ PDisposition7l V Z Date of Dis Disposition ��—�jw Place of t e W (address) t1J N /section) /lotnumber/ (grave number) g, Name of Sexton or Pers Charge of Premises L� i�.vc 4-.--ml44,4 z, (please print) W Signature Title DOH-1555(07/18)p 10 2 Public Health Law Sec. 4145(2t)) 0 .13 4 W i Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#