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Fitzsimmons, Harold Patrick i it i NEW YORK STATE DEPARTMENT OF HEALTH I ' Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Harold Patrick Fitzsimmons Male Date of Death Age If Veteran of U.S.Armed Forces, 06/26/2021 80 Years War or Dates 1960-1966 Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital p Manner of Death © Natural Cause 0 Accident ❑Homicide 0 Suicide 0 Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title O Sidharth Jogani MD Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs • 4501 352 Burial Date Cemetery,Crematory or Facility Name 07/01/2021 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation Z 0 Removal Date Place Removed and/or and/or Held N Hold Address CO 0 Date Point of Cl) Li Transportation Shipment p by Common Carrier Destination Date Cemetery Address 0 Disinterment 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 H. Remains are Shipped,If Other than Above 2 Address Ix W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/28/2021 Registrar of Vital Statistics Jo/in cPautFranc&(E(ectronicatty Signed) (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: IH Z Date of Disposition )/i/0..02.1 Place of Disposition P;fti V.Cui Grti c cry W 1 (address) W CO (section) "� Si!..), (lot number) (grave number) 0 v • Name of Sexton or Person in Charge of Premises y ��� 'r� Z (please print) Title f W Signature fciri DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) � 01-4 902 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#