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Kilburn, Marshall Robert It ys NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Marshall Robert Kilburn • Male Date of Death Age If Veteran of U.S.Armed Forces, 05/26/2021 21 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital LU p Manner of Death El Natural Cause 1=1 Accident El Homicide ©Suicide 0 Undetermined Pending UJ C.) Circumstances Investigation 0 Medical Certifier Name Title David DeCelle Coroner Address 40 McMaster Street,Ballston Spa,New York 12020 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 309 Burial Date Cemetery,Crematory or Facility Name 06/01/2021 Pine View Crematory Entombment Address ElCremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held NH Hold Address 0 d Date Point of U) ❑Transportation by Common Shipment Carrier Destination EiDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 2 Address fr W— a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/27/2021 Registrar of Vital Statistics John Paul Franck(E(ectronica((ySigned) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— J W Date of Disposition (p'j I Zi Place of Disposition 2 (address) W U) CC (section) n(lot number) (grave number) Name of Sexton or Person in Charge of Prises P�� 1--�h►nL`! Z ` (Pleas print/ lL Signature Title M k} DOH-1555(07/18)p 1 of 2 1 ` Public Health Law Sec. 4145(2b) 0.4'-i 1 8 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#