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Hurlburt, Edwin S. Zc NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Edwin S.Hurlburt Male Date of Death Age If Veteran of U.S.Armed Forces, 05/13/2021 73 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Whitehall Town Street Address 9863 Route 4 16,Whitehall Town, New York 12887 p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined IDPending Circumstances Investigation W Medical Certifier Name Title 0 William Parker MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Whitehall Town 5766 4 ❑Burial Date Cemetery,Crematory or Facility Name 05/17/2021 Pine View Crematory ❑Entombment Address aCremation Queensbury Town,New York ❑Donation OZEl Removal Date Place Removed and/or and/or Held Hold Address O Date Point of U) ❑Transportation p by Common Shipment Carrier Destination ❑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 F— Remains are Shipped,If Other than Above Address CC W C' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/17/2021 Registrar of Vital Statistics (Patti Gordon(E(ectronica1TySigned) (signature) District Number 5766 Place Whitehall Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 5114 11 Place of Disposition 2 (address) W NCC (section) (lot number) r (grave number) 0 Name of Sexton or Person in Charge of Premises Z (plea eprint) W Signature Title (r .4ive DOH-1555(o7/18)p i of 2 Public Health Law Sec. 4145(2b) + t t f Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#