Ostrander, Keith 07/26/2016 11:25 5187477548 s MBKILMER PAGE 01
NEW YORK STATE DEPARTMENT OF HEALTH 513
Vital Records Section Burial - Transit Permit
r,.).. Name First Middle Last Sex
Keith Roger Ostrander Male
Date of Death Age If Veteran of U.S.Armed Forces,
July 20,2016 64 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines of Glens Falls
Manner of Death X❑ Natural Cause ❑ Accident p Homicide n Suicide El Undetermined 71 Pending
Circumstances Investigation
Medical Certifier Name Title
• Melissa Decker, • Dr,
Address
100 Park Street Glens Falls, NY 12801
'•
; Death Certificate Filed District Number Register.NN r
• City, Town or Village Glens Falls .56G'/ ,�
0 Burial Date Cemetery or Crematory
July 22, 2016 Pine View Cremator)/
-`s Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
• Date I 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
i..
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 123803
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 dejrcr' eL✓ dicated.
Date Issued O)�ZiAla Registrar of Vital Statistics
(signature)
District Number S 6a Place is-
°: `y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 07/22/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /� e(lot number) (grave number)
"• Name of Sexton or Person in Charge of Premises �'+ ease pri _51i
nt
Signature -- Title - 174
(over)
DOH-1555(02/2004)
Ostrander
F \
t Lot No. 8 2-E
ldress 11 Oakwood Drive So. Glens Falls NY 12803 Section No.
Amer Mr . Bruce M. Ostrander Jr . Plot Mohican
lte 4/29/94
App r o x . 3 3 Superficial ft. @
►cation Bounded North by Williams. South by Vacant . East by Brown, West by Vacant
)rner Posts
sty , /
marks `3 � c'.0 elk I c� � � J "Yl‘SS k�4:, 4 \f1�� c uet_ 'Kc 1-�4
i_rc:93_________s=ei \-1c �. ICI c w"6 i ( R e C^� r�.vsAc.11..�e�
eed No. (and changes) 2580
tyment Record paid in Full 4/29/94 ( $350 . 00 )
ecord of Interments
Bruce M. Ostrander Sr . 5/3/94 ..-UCC
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orm No. 01
OSTRANDER
NAME ' Age: 6 4
Keith R Ostr nder,� g
Lot Owner: Bruce M Ostrander Jr.
Lot# Mohican 82E Grave# 1A
Case: Urn
Died: 7.2 0.2 01 6 Interred: 8.2 4 .2 3
Funeral Home: M.B. Kilmer
Cemetery: Pine View