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Bushey, Edward Donald obi NEW YORK STATE DEPARTMENT OF HEALTH t -( Vital Records Section Burial - Transit Permit Name First Middle a Last Sex Edward Donald Bushey Male Date of Death Age If Veteran of U.S. Armed Forces, .. October 11, 2020 91 War or Dates Place of Death Hospital, Institution or City, Town or Village Street Address 1285 Burgoyne Ave Manner of Death r771.] Natural Cause ❑ Accident n Homicide n Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title William A. Tedesco, M.D. Dr. k Address 3 Irongate Center Glens Falls, NY 12801 Death Certificate Filed District Nuinber Register Number City, Town or Village f d QI(p ❑Burial Date Cemetery or Crematory . _ October 1, 2020 Pine View Crematory 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 IIP Date Place Removed n Removal and/or Held 14 I I and/or Address fir, Hold C Date Point of ❑Transportation Shipment by Common Destination 0. Carrier ❑ Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment _ Permit Issued to Registration Number ., Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 s; Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ` Address 45, Permission is hereby granted to dispose of the human re ins described abo e as indicated. Date Issued 10110-2020 Registrar of Vital Statistics Y L (signatu District Number576.5 Place c 'r J .. "' - ) -Fr }k q L aAd - I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 10/15/2020 Place of Disposition Quaker Road Queensbury,NY 12804 P,(04.(/,t,,,, c,r fr/ (address) (section) (lot number) (grave number) tai Name of Sexton or Person in Charge of Premises T�-C& .t y 5v.hre-5 ,Z- (please print) W' /f Signature ! Title Gre.►n/or 3 - (over) DOH-1555 (02/2004) Public Health Law Sec. 4145(2b) 4 10 0 1 4 1 Receipt Human remains of {4 delivered on ; , 20 • Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# -