Garnsey, Samuel Chester NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Pe it
Bureau of Vital Records
Name First Middle Last Sex
Samuel Chester Garnsey Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/20/2021 72 Years War or Dates
H Place of Death Hospital,Institution or
Z-City,Town or Village Northumberland Hamlet Street Address 12 Second Street,Northumberland Hamlet,New York 12831
pManner of Death Natural Cause Accident Homicide Suicide ❑Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Mark Quaresima MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Northumberland Town 4563 4
▪Burial Date Cemetery,Crematory or Facility Name
04/22/2021 Pine View Crematory
❑Entombment Address
O Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
F—N Hold Address
0
Date Point of
to ❑Transportation Shipment
p by Common
Carrier Destination
El 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
i.. Remains are Shipped,If Other than Above
3 Address
2
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/22/2021 Registrar of Vital Statistics Denise D Murphy(Electronically Signed)
(signature)
District Number 4563 Place Northumberland Town, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZlJ
Date of Disposition /1 Z.31 Z1 Place of Disposition —17ine(11+—
(address)
W
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Pre ' e ! "t"
(pie a print)
W rioCA
Signature Title
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 01 4 7 3 2
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#