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Hermance, James Lewis g,1 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James Lewis Hermance Male Date of Death Age If Veteran of U.S.Armed Forces, 09/22/2021 82 Years War or Dates 1956-1958 Place of Death Hospital,Institution or Z City,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing Manner of Death Undetermined 0 Pending G © Natural Cause �Accident �Homicide �Suicide W Circumstances Investigation Medical Certifier Name Title 0 Thomas Kandora MD Address 17 Madison St,Granville Village,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville Village 5725 50 ❑Burial Date Cemetery,Crematory or Facility Name 09/27/2021 Pine View Crematory 0 Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Z Removal Date Place Removed - and/or and/or Held - Hold Address N O. Date Point of N Transportation Shipment Q by Common Carrier Destination 0 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 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/27/2021 Registrar of Vital Statistics Wichard12Q6erts(ECectronica1ty Signed) (signature) District Number 5725 Place Granville Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W it of Disposition 12��ti] Place of Disposition ►Rc �— (address) ILJ CC (section) a (lot num _ (grave number) n+ 0 Name of Sexton or Person in Char of Premises (please p t) W � Title ro� Signature DOH-1555(07/18)p 1 of 2 P 4 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burialpermit Official Funeral Directors Reg.or License#