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Powers, Robert James t j NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert James Powers Male Date of Death Age If Veteran of U.S.Armed Forces, 06/16/2021 71 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address 77 Park Avenue, Fort Edward Town, New York 12828 p Manner of Death © Natural Cause El Accident ❑Homicide Suicide Undetermined Pending U Circumstances Investigation UJ Medical Certifier Name Title 0 Rita All NP Address 9 Carey Road,Queensbury Town, New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 37 ❑Burial Date Cemetery,Crematory or Facility Name 06/22/2021 Pine View Crematory ❑Entombment Address Cremation Queensbury Town,New York ❑Donation o• ElRemoval Date Place Removed and/or and/or Held N Hold Address 0 CI. Date Point of U) Li 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 E— Remains are Shipped,If Other than Above 2 Address CC W _— a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/22/2021 Registrar of Vital Statistics Aimee L Mahoney(E(ectronicatTy Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IF- Z Date of Disposition �_. W }�� � ) Place of Disposition j (address) W CC (section) (lot number) (grave number) GName of Sexton or Person in Charge of Premises TzChtt.y S tlii BLS Z (please print) W Signature Title,,p/A.,-." GfeM•:43f DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#