Hilpertshauser Jr, Ernest •
NEW YORK STATE DEPARTMENT OF HEALTH e R '*� 't 3 t2_
Vital Records Section Burial - Transit Permit
iName First Middle Last Sex
Ernest Hilpertshauser;"s.Jr. Male
<'' Date of Death Age If Veteran of U.S. Armed Forces,
ia
Jul 3 2011 80 War or Dates No
Place of Death Tn. of Moreau Hospital, Institution or 73 Fort Edward Rd.
' •. City, Town or Village Street Address
>. Manner of Death®Natural Cause El Accident El Homicide El Suicide EiUndetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
'. John Stoutenburg MD
Address
100 Park St. Glens Falls New York 12801
i Death Certificate Filed Tf M District Number /� Register Number
igi City, Town or Village n. o oreau 7 J(o A
Date Cemetery or Crematory
❑Burial July 5, 2011 Pine View Crematory
Address
flCremation 21 Quaker Road Queensbury, New York 12804
FDate Place Removed
fl Removal and/or Held
r: and/or Address
a Hold
i
0 Date Point of
%EiTransportation Shipment
B by Common Destination
Carrier
:.::: Disinterment Date Cemetery Address
:.:. Reinterment Date Cemetery Address
Iiii Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01078
iiiii
iiiii Address
136 Main St. South Glens Falls, New York 12804
iii Name of Funeral Firm Making Disposition or to Whom
"' Remains are Shipped, If Other than Above
Address
:
iiiin Permission is hereby granted to dispose of the human remains described above as indicated.
':` Date Issued 7-�.201 1 Registrar of Vital Statistics � "'_ "`1
1...t
gnature)
111 District Number �(,
L� a Place Tn. of Moreau
I certify that the remains of the decedent identified above were disposed of in accord/ance�with this permit on:
Date of Disposition "}-b-(` Place of Disposition -P,A,Vitad uenr.ct
2 (address)
LU
CC (section) fN (lot num (grave number)
G Name of Sexton or Per on in Char•, of Premises L nyt
z /�L � (please print)
fii Signature If l";L ! Title C'i v.m ifweL.
(over)
DOH-1555 (9/98)