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Mueller, Ernest Theodore li y fl NEW YORK STATE DEPARTMENT OF HEALTH e t Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Ernest Theodore Mueller Male Date of Death Age If Veteran of U.S.Armed Forces, 05/11/2021 80 Years War or Dates 1958-62 F Place of Death Hospital,Institution or W City,Town or Village Valatie Village Street Address Barnwell Nursing And Rehabilitation Center p Manner of Death © Natural Cause ❑Accident El Homicide ❑Suicide ❑Undetermined ❑Pending UCircumstances Investigation Wp Medical Certifier Name Title Kathleen Steiger NP Address 3230 Church St,Valatie Village,New York 12184 Death Certificate Filed District Number Register Number City,Town or Village Valatie Village 1023 22 Burial Date Cemetery,Crematory or Facility Name 05/13/2021 Pine View Crematory ❑Entombment __Address — 1 Cremation Queensbury Town,New York ElDonation Removal Date Place Removed and/or and/or Held I Hold Address N 0 CL Date Point of U) Li Transportation p by Common Shipment Carrier Destination ElDisinterment 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 M Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/12/2021 Registrar of Vital Statistics Barbara Ann(Fischer(E(ectronica((ySigned) (signature) District Number 1023 Place Valatie Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition s / ,1i4 Ill Place of Disposition � L r- 2 (addres W N CC (section) (tot number) (grave number) c, Name of Sexton or Person in Charge of Premises It L g — `.. �J+�1,��$ Z (p/e a print) W Signature Title 54411V214- DOH-1555(o7/t8)p 1 of 2 Public Health Law Sec. 4145(2b) 014794 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#