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Lohman, Robert Somers sS NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transitermit Bureau of Vital Records Name First Middle Last Sex Robert Somers Lohman Male Date of Death Age If Veteran of U.S.Armed Forces, 01/21/2021 82 Years War or Dates 1,., Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 8 Finch Way F,Queensbury Town,New York 12804 IU IU p Manner of Death © Natural Cause ElAccident 0 Homicide ElSuicide El Undetermined ElPending V Circumstances Investigation W Medical Certifier Name Title 0 Marianne Mustafa MD Address 6 Medical Park Drive 208,Malta Town,New York 12020 Death Certificate Filed District Number RF51st :J mber City,Town or Village Queensbury 5657 31 Burial Date Cemetery,Crematory or Facility Name 01/27/2021 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation 0 El Removal Date Place Removed and/or and/or Held ~ Hold Address N 0 IL Date Point of Cl) L j Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ElReinterment 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 Address CC , Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/26/2021 Registrar of Vital Statistics CaroCineJ(i&degarie(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 I,7g1 21 Place of Disposition . ,—IL 4,` W 2 (address) ILI N LC (section) (lot number)_ (grave number) GName of Sexton or Person in Charge of Premiss �rt. 4-4 A 41 fi Z (piese print) W Signature Title /1'4''�' I'D DOH-1555(07/18)p 1 of 2 .r Public Health Law Sec. 4145(2b) 0144 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#