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VanAlphen, Ramon NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Ramon VanAlphen Male Date of Death Age If Veteran of U.S. Armed Forces, 04/08/2018 75 Years War or Dates 1961-1965 Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Gwendolyn Morris-Dickinson PA Address yt, 170 Warren St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 172 ❑Burial Date Cemetery or Crematory 04/10/2018 Pine View Crematory ❑Entombment Address j'®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 ❑Reinterment Date Cemetery Address 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 04/09/2018 Registrar of Vital Statistics ti6ertA Curtis(ECectronicaCCySigned) (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: Date of Disposition l illhe Place of Disposition 1' (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of Pr mises //,.. _S6A- (p print) Signature Title GiTP^ r��, (over) DOH-1555 (02/2004)