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Corbett Jr.,Lawrence Edward 11111 NEW YORK STATE DEPARTMENT OF HEALTH "+.` Burial - Transit Perniit Bureau of Vital Records Name First Middle Last Sex Lawrence Edward Corbett Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 10/20/2020 99 Years War or Dates 1942-1958 E Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc W Manner of DeathUndetermined Pending © Natural Cause ❑Accident Homicide Suicide❑ ❑ ❑ UJ Circumstances Investigation W Medical Certifier Name Title C3 Carrie Miron PA --_- —_ --- Address 319 Broadway, Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 89 ❑Burial Date Cemetery,Crematory or Facility Name 10/21/2020 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town,New York ❑Donation ❑Removal Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of U) ❑Transportation p by Common Shipment Carrier Destination ❑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 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/21/2020 Registrar of Vital Statistics Aimee Mahoney(ECectronicaCCySigned (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: H ' Z Date of Disposition /D Iu,WW Place of Disposition `F,,,,�111,/.r 2 (address) W NCC (section) n (lot number) (grave number) 0 Name of Sexton or Person in Charge of remises IL(pprint) /' s 4/1411 Signature Title ( 11 t''u DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014. 13 4 t Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#