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Kaiser, Gary Lyle NEWYORKSTATEDEPARTMENTOFHEALTH - i Bureau of Vital Records BurialTransit Permit Name First Middle Last Sex Gary Lyle Kaiser Male Date of Death Age If Veteran of U.S.Armed Forces, 10/26/2020 70 Years War or Dates 1973-1975 F Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 76 Alpine Avenue, Queensbury Town, New York 12804 ILLJ p Manner of Death © Natural Cause Accident Homicide Suicide Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title CI John Lukaszewicz MD Address 101 Ridge Street 2,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 200 ElBurial Date Cemetery,Crematory or Facility Name 10/29/2020 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York Donation O ❑Removal Date Place Removed and/or and/or Held N Hold Address 0 IL Date Point of V) j Transportation by Common Shipment Carrier Destination E 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 H Remains are Shipped,If Other than Above 2 Address Ix W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/29/2020 Registrar of Vital Statistics CarolineJfi&cfegardf Barber(ECectronicallySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition Jd/30 Po Place of Disposition address) W Ce (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises �!+ ,- �"44� (pleftse print) W Signature Title CI'1("'4�H- DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 'J 1 416 3 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#