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Valis Jr., Edwin Philip
4.5 • • NEW YORK STATE DEPARTMENT OF HEALTH Transit Permit Bureau of Vital Records Burial - Name First Middle Last Sex Edwin Philip Valis Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 11/18/2021 56 Years War or Dates . Place of Death Hospital,Institution or WCity,Town or Village Chester Town Warren Street Address 1067 Landon Hill Road,Chester Town Warren,New York 12817 WManner of Death © Natural Cause 1=1 Accident ❑Homicide ❑Suicide ❑Undetermined Pending V Circumstances Investigation Lu Medical Certifier Name Title Lynn Keil PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village 3551 Burial Date Cemetery,Crematory or Facility Name 11/20/2021 Address Pine View Cemetery ❑Entombment Cremation Queensbury, New York Donation 0 ElRemoval Date Place Removed and/or and/or Held Hold Address CO 0 Date Point of tt) Li Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 g Address Q W Q' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/22/2021 Registrar of Vital Statistics (signature) District Number 3551 Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 1I/t2('L{ Place of Dispositionn710"+- 2 (address) W CC (section) (l/!7 ber) (grave number) Gtr f�'Name of Sexton or Person in Charge of Pr ises � ' ��'— Z (p print W Signature ��7 Title �r-fn"W � DOH-1555(o7/18)p i of 2 • 015354 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#