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Heinz, Herbert NEW YORK STATE DEPARTMENT OF HEALTH ' S //b Vital Records Section Burial - Transit Permit Name First Middle Last Sex Herbert Heinz Male Date of Death Age If Veteran of U.S. Armed Forces, September 30, 2018 79 War or Dates Place of Death Hospital, Institution or , City, Town or Village Kingsbury Street Address 1 Gulf Lane ilt Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title Robert Love, Dr. Address 3 Irongate Center Glens Falls, NY 12801 Death Certificate Filed District Number Register Number ,: City, Town or Village Kingsbury 3-7 e A / C ❑Burial Date Cemetery or Crematory October 1, 2018 Pine View Crematory ri ❑Entombment Address F©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination a Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number - Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above r Address wIL. Permission is hereby granted to dispose of the human rema escribed above as indicated. Date Issued /e/-/—/g Registrar of Vital Statistics c z.-Q (signature) Distri ct Number —`� )/� 7 (c Place lc ,-Z-l' y75 I certify that the remains of the decedent identified above were dispose of in accordance with this permit on: at Date of Disposition 10/01/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) Iclot number) (grave number) r i Name of Sexton or Person in Charge of Premises4 P+�t1P�'� th" (ple a print) Signature +6' Title /nFA►97 L (over) DOH-1555 (02/2004)