Morris, Martin NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Martin Lynam Morris Male
4-- Date of Death Age If Veteran of U.S. Armed Forces,
July 16, 2015 71 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 9 Bly Ave
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Max Crossman, M.D. Dr.
Address
65 Poultney Steet Whitehall, NY 12887
Death Certificate Filed District Number Register Number
City, Town or Village 57 6 a. l/
0 Burial Date Cemetery or Crematory
July 21, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
41
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
4 LI Disinterment
Date Cemetery Address
El Reinterment
Date Cemetery Address
-rPermit Issued to Registration Number
` Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
T Address
136 Main Street, South Glens Falls NY 12803
1,4
, 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 remai described above as indicated.
41 Date Issued 7-3) a O i s Registrar of Vital Statistics
` �� (signature)
A. E District Number 57(oa Place iper,,, rt kj,''^�S6�
1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/21/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) / lot number) (grave number)
Name of Sexton or Person in Charge of Premises 4► N+
4
(plebse print)
Signature '"" Title rleov
a"t
(over)
DOH-1555 (02/2004)