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Simard, Louis — : it y NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Louis Simard Male Date of Death Age If Veteran of U.S.Armed Forces, 06/13/2021 63 Years War or Dates 1... Place of Death Hospital,Institution or W City,Town or Village South Glens Falls Village Street Address 8 3rd Street,South Glens Falls Village, New York 12803 p Manner of Death ©Natural Cause Accident El Homicide ❑Suicide El Undetermined Pending U Circumstances Investigation WU Medical Certifier Name Title CI Glen Anderson PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village South Glens Falls Village 4524 15 EIBurial Date Cemetery,Crematory or Facility Name 06/17/2021 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held H Hold Address N 0 d Date Point of U) ❑Transportation p by Common Shipment Carrier Destination +, ElDisinterment Date Cemetery Address Ei 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 — Remains are Shipped,If Other than Above N Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/17/2021 Registrar of Vital Statistics Shannon Kelleher(Electronically Signed) (signature) District Number 4524 Place South Glens Falls 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 (pllgl Place of Disposition / rd �r 2 address) W U) CC (section) number) (grave number) 0 Name of Sexton or Person in Charge of Premises dlot �4 r 1 11- Z /pleapiint/ al Signature Title Ii i�- DOH-1555(o7/18)pi of 2 9 Public Health Law Sec. 4145(2b) , 1_4 8 6 7 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#