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Morehouse, Jeffery E I 6No NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jeffery William Morehouse Male Date of Death Age If Veteran of U.S. Armed Forces, 12/13/2017 65 Years War or Dates ,. — Place of Death Hospital, Institution or LUCity, Town or Village Glens Falls Street Address Glens Falls Hospital 0© Manner of Death Natural Cause ❑Accident ['Homicide 0 Suicide ❑Undetermined ❑Pending Circumstances Investigation ku Medical Certifier Name Title Sean Bain MD Address ` 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 640 ❑Burial Date Cemetery or Crematory 12/15/2017 Pine View Crematory ';❑Entombment Address ®Cremation Queensbury, New York Date Place Removed Z ri Removal and/or Held and/or Address Hold CO 0 Date Point of O. ❑Transportation Shipment ci by Common Destination Carrier 5 Disinterment Date Cemetery Address ❑Renterment 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 f'3 Name of Funeral Firm Making Disposition or to Whom b Remains are Shipped, If Other than Above Address IS a` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/15/2017 Registrar of Vital Statistics RQ6ertf7Curtis ECectronica1TySigned- (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: W. Date of Disposition 1'Zjlg jil Place of Disposition Tr�rl�� „;,,_ I (address) (section) (lot number) (grave number) 3 Name of Sexton or Person in Charge of Premises (1..)44L S4'-4,t 2 (p se print) Signature �^3 i r.as Title A►St1i.L (over) DOH-1555(02/2004)