Wehner, Horst Friedrich cjg
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Horst Friedrich Wehner Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/25/2021 70 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Fort Edward Village Street Address 40 Broadway,Fort Edward Village,New York 12828
p Manner of Death ❑i Natural Cause ❑Accident Homicide 0 Suicide El Undetermined D Pending
W Circumstances Investigation
ILL) Medical Certifier Name Title
O Melanie Duerr NP
Address
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 57
❑Burial Date Cemetery,Crematory or Facility Name
09/27/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
Donation
O ❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
Cl) j Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Reinterment
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
—. Remains are Shipped,If Other than Above
5 Address
C
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/27/2021 Registrar of Vital Statistics /?imeeL Malang(rElectronicalySignerl)
(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:
Z Date of Disposition � Z��t� Place of Disposition n.CV` „Tft
2 (address)
W
CC (section) (lot number) (grave number)
gName of Sexton or Person in Charge of mises (pt ase print)
W Signature Title (�40'PRIM
DOH-1555(07/18)p t of 2
0 1. . J
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#