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Poling, James Douglas 4 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex James Douglas Poling Male Date of Death Age If Veteran of U.S.Armed Forces, 09/29/2021 47 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Village Street Address 227 Broadway#5, Fort Edward Village, New York 12828 W p Manner of Death 111Natural Cause ❑Accident Homicide ❑Suicide Undetermined ©Pending Circumstances Investigation U W Medical Certifier Name Title L3 Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 58 Burial Date Cemetery,Crematory or Facility Name 10/01/2021 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held N Hold Address 0 O. Date Point of U) I 1 Transportation Shipment p by Common Carrier Destination Date Cemetery Disinterment Date Ceme Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Horn ort _Award 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 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/30/2021 Registrar of Vital Statistics Aimee L Mahoney(ECectrouica((y Signed) (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"mi on: W Date of Disposition ION114 Place of Disposition � 'ncW�� ��•lirdd� 2 (address) W CC (section) 9t number) (grave number) amvii 0 Name of Sexton or Person in Charge of remises %4 Z (please Ft, /PFW Signature Title M ;OvZ DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt m f,r` 1 Human remains of `` delivered on , 20 Pine View Cemetery Representing the funeral home named on buria ,permit Official Funeral Directors Reg.or License#