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Royallminns, Jacques Paul NEW YORK STATE DEPARTMENT OF H EALTH Bureau of Vital Records Burial - Transi Per n it Name First Middle Last Sex Jacques Paul Royallminns Male Date of Death Age If Veteran of U.S.Armed Forces, 11/08/2021 74 Years War or Dates unknown Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital ip Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation QMedical Certifier Name Title Christopher Smith MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 499 ElBurial Date Cemetery,Crematory or Facility Name 11/09/2021 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation Z Date Place Removed 0 ❑Removal and/or and/or Held Hold Address tilh 0 a- Date Point of CA Li Transportation p by Common Shipment Carrier Destination Date Cemetery Address El Disinterment ❑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 Remains are Shipped,If Other than Above 2 Address E W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/09/2021 Registrar of Vital Statistics Men Andrew Curtis(E(ectronicalfySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t. 04-1k w Date of Disposition I�i!o�Z Place of Disposition (address) W N 0(section) A (lot number) c (grave number) A4bI 0 Name of Sexton or Person in Charge of P mises Z (p le.se print) 11.1 201 Signature Title l DOH-1555(07/t8)p 1 of 2 a y Public Health Law Sec. 4145(2b) Receipt 1 Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit 1 Official Funeral Directors Reg.or License# 1