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SteMarie, Maurice Pierre F113$ NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Maurice Pierre SteMarie Male Date of Death Age If Veteran of U.S.Armed Forces, 10/17/2020 78 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Kingsbury Town Street Address 118 North Street,Kingsbury Town,New York 12839 LLI "p Manner of Death ©Natural Cause ❑Accident ❑Homicide 0 Suicide 0 Undetermined Pending Circumstances Investigation W Medical Certifier Name Title CI David Foote MD Address 340A Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 32 ElBurial Date Cemetery,Crematory or Facility Name 10/19/2020 Pine View Crematorium ElEntombment Address ElCremation Queensbury Town,New York Donation Date Place Removed ZO ❑Removal and/or Held H and/or U) Hold Address 0 Date Point of U) Li Transportation Shipment p by Common Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom i- Remains are Shipped,If Other than Above "g Address CC W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/19/2020 Registrar of Vital Statistics Cynthia Bardiin(E(ectronica1Ty Signed) (signature) District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k Date of Disposition 10 in120 Place of Disposition �., / W (address) W U)Et (section) 4(lot number) (grave number) Name of Sexton or Person in Charge of Pises (pleaepr/nt) Z (6411111112111 W Signature Title DOH-1555(07/18)p 1 of 2 _ Public Health Law Sec. 4145(2b) • f ..L.==;`. Receipt Human remains of delivered on ' . , 20 ,....+ Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# i