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Zimmer, David r - 14--5 v NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section 777.1-4 Name First Middle Last Sex David W. Zimmer Male Iss Date of Death Age If Veteran of U.S. Armed Forces, January 4, 2017 68 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 0 Suicide n Undetermined ❑ Pending ',. Circumstances Investigation Medical Certifier Name Title Sanjay Taneja, M.D. Dr. Address 294 Grand Avenue Saratoga Springs, NY 12866 Death Certificate Filed District Number to, Register Number 12_ - City, Town or Village Glens Falls ❑Burial Date Cemetery or Crematory January 9, 2017 Pine View Crematory ' 1:1 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 142 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ElReinterment Date Cemetery Address IS' Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 43 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 , :M Permission is hereby granted to dispose of the human mains de cribed a ove as indi ated.1 Date Issued Registrar of Vital Statistics `signature) ry District Number �p0/ Place 74; 1/1l: 1 � (, I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on: Date of Disposition 01/09/2017 Place of Disposition Quaker Road Queensbury,NY 12804 I,' (address) (section) // (lot number) (grave number) Name of Sexton or Person in Charge of Premises C n i1L.r Am/ft 2 please print) ,p Signature �� Xa., Title (Ff.t4A-Tte., (over) DOH-1555 (02/2004)