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Stimpson Jr., Ernest NEW YORK STATE DEPARTMENT OF HEALTH if 3° Vital Records Section Burial - Transit Permit Name First Middle Last Sex Ernest A. Stimpson Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, January 2, 2017 56 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 ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Joseph C. Mihindu, M.D. Dr. Address 52 Park St. Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls c (O ) 's 0 Burial Date Cemetery or Crematory January 9 2017 Pine View Crematory ❑Entombment Address Ai©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held ' and/or Address - Hold Date Point of -❑Transportation Shipment by Common Destination i Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address El Reinterment t Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 °'':' Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom kµ°° Remains are Shipped, If Other than Above Address On„..` Permission is hereby granted to dispose of the human remains described above as indicated. "" Date Issued 1 j 5 1 20 J '7 Registrar of Vital Statistics �j CAi""0 ib' _S. � ‘'' .n/` � (signature) District Number 5 bo 1 Place 6 5 ru \\ S/a) i./ certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 01/06/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) / (lot number) (grave number) - Name of Sexton or Person in Charge of remises t�h r! T 3M"tit 9 /��// ( lease print) ; Signature LAC Title (peMI (over) DOH-1555 (02/2004)