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Goodspeed, Keith Reuben NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Keith Reuben Goodspeed Male Date of Death Age If Veteran of U.S.Armed Forces, 08/24/2021 25 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 212 C Burke Drive, Queensbury Town, New York 12804 1L Manner eat � of Dh ❑ Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ©Pending tL Circumstances Investigation U Q Medical Certifier Name Title Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 176 ❑Burial Date Cemetery,Crematory or Facility Name 08/27/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Z ❑Removal Date Place Removed and/or and/or Held _ Hold Address O NLi Date Point of p by Common Shipment -- Carrier Destination Date Cemetery Address ❑Disinterment ❑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 I— Remains are Shipped,If Other than Above 5 Address Cr W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/27/2021 Registrar of Vital Statistics Caroline 9fi&c1egarde Barber(6(ectronica1ty Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H J Z Date of Disposition $13p I'il Place of Disposition (address) W CC (section) n(/fit number) � (grave number) 0 Name of Sexton or Person in Charge of emises i` rd► rin.•► (pi e print) / ,, lL Signature Title ( �A'1.f1IN. DOH-1555(o7/18)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#