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VanGuilder Sr., Alfred LeRoy NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Alfred LeRoy Van Guilder Sr Male Date of Death Age If Veteran of U.S.Armed Forces, 10/05/2021 79 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address Glens Falls Hospital CI Manner of Death © Natural Cause n Accident ❑Homicide El Suicide 1=1 Undetermined El Pending ui Circumstances Investigation W Medical Certifier Name Title II Gamal Khalifa MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 0 Burial Date Cemetery,Crematory or Facility Name 10/08/2021 Pine View Cemetery Entombment Address ElCremation Queensbury Town,New York 0 Donation Removal Date Place Removed and/or and/or Held H Hold Address N O. Date Point of Cl) ❑Transportation Shipment Q by Common Carrier Destination El Disinterment 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 1- Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/07/2021 Registrar of Vital Statistics 4WertAndrew Curtis(ECectronicalty Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F— W Date of Disposition � a i Place of Disposition a, Qun Qp © t rrs `bu l r N ya8c (address) V W l/ as (I) section ''(lot number) (grave number) cc GName of Sexton or Person in Charge of Premises ��^^' (please print) Z W Signature4,"4:4 D Title i DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012876 Receipt Human remains of ,--: / ,- , . _ „ f -,___ delivered on , %. - , 20i _ I Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# uancu i 1 Lip,r (17-11 Lot No. 29E Oueensburv, NY Address 477 Uppper Sherman Avenue Section NO•Erie Owner Alfred and Rita VanGuilder Plot Erie Date Nov_ 13, 2013 67 Superficial ft. @ LocationBounded West by Wetmore, North vacant. East vacant, South Vacant Corner Posts • Remarks 5.18-793-2858 Deed No. (and changes) 3832 Payment Record Paid iu full check # 4309 . receipt # 0.02k1 LO.r , Record of of Interments i I NL-ri L ...),,,_.„...._ 1 A i rc..e/ Niangi;ldc. . )a.8.,2 V A 1 2 1 4 n, 3 y _, . i ,... 1 1 xy. 1 li i I 1 i 1 i Form No. 01 VANGUILDER NAME Alfred VanGuilder Age: 79 Lot Owner: Alfred & Rita VanGuilder Lot# Erie 29E Grave# 1 Case: Concrete Died: 1 0.5.2 1 Interred: 1 0.8.2 1 Funeral Home: M.B. Kilmer Cemetery: Pine View