Carpenter, Ryan Michael �....,._.� F / I 1114
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ryan Michael Carpenter Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/08/2020 36 Years War or Dates
j_ Place of Death Hospital,Institution or
W City,Town or Village Fort Edward Village Street Address 3 Terrace Place, Fort Edward Village, New York 12828
{p Manner of Death EI Natural Cause Accident ElHomicide ElSuicide ❑Undetermined Pending
U Circumstances Investigation
WW Medical Certifier Name Title
Robert Lemieux Coroner
Address
415 Lower Main Street, Hudson Falls Village,New York 12839
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 83
i
Burial Date Cemetery,Crematory or Facility Name
10/13/2020 Pine View Crematory
❑Entombment Address
aCremation Queensbury Town,New York
❑Donation
❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
tt) ❑Transportation Date Point of
p by Common Shipment
Carrier Destination
12 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
a Address
CC
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/13/2020 Registrar of Vital Statistics Aimee Mahoney(ECectronicatTy Signed)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i J
W Date of Disposition /o)ij l70 Place of Disposition ✓l0�-
2 (address)
w
N (s ct/on) numbe (grave number)
3(lot
irt.
0 Name of Sexton or Person in Charge of Premi
Z (ple eJprint)
W Signature Title L
DOH-1555(07/18)p i of 2
c_... -1
Public Health Law Sec. 4145(2b) U 1106
Receipt
Human remains of ='~ y,.? A.. ,-- delivered on 20
Pine View Cemetery Representing the fune al home named on burial aermit
Official Funeral Directors Reg.or License# /