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Terry, Kristopher John kt 'IL NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kristopher John Terry Male Date of Death Age If Veteran of U.S.Armed Forces, 11/18/2021 46 Years War or Dates F- Place of Death Hospital,Institution or Z City,Town or Village Whitehall Town Street Address 9882 State Route 4,Whitehall Town, New York 12887 W Manner of Death UndeterminedPending W ❑ Natural Cause ©Accident El El ❑ 11 Circumstances Investigation W Medical Certifier Name Title Cl John Aiken Coroner Address 40 Burquist Road,Fort Ann Town,New York 12827 Death Certificate Filed District Number Register Number City,Town or Village Whitehall Town 5766 14 ❑Burial Date Cemetery,Crematory or Facility Name 11/22/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation OZ ❑Removal Date Place Removed and/or and/or Held I Hold Address N 0 Q. ❑Transportation Date Point of p by Common Shipment Carrier Destination Date Cemetery Address El 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 1- Remains are Shipped,If Other than Above 2 Address C W EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/22/2021 Registrar of Vital Statistics (Patti Gordon(E(ectronicallySigned) (signature) District Number 5766 Place Whitehall Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t— W Date of Disposition �l 21� Zr Place of Disposition 1riA c i/� /v+-d 2 (address) W N O (section) gt number) e number) 0 Name of Sexton or Person in Charge of Pre i es �- ......coIG\ Md� z (pleas riot) lL Signature Title a-40"e DOH-1555(07/18)p 1 of 2 15362 Public Health Law Sec. 4145(2b) Receipt Human remains of • delivered on , 20 air Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#