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Burgess Jr., Dr Ernest Clayton NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dr. Ernest Clayton Burgess Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 10/26/2021 89 Years War or Dates t,,,. Place of Death Hospital,Institution or Z-City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death © Natural Cause 0 Accident 0 Homicide ❑Suicide Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title CI Asim Chaudry MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 469 ❑Burial Date Cemetery,Crematory or Facility Name 10/28/2021 Plne View Crematory 4 0 Entombment Address ElCremation Queensbury Town,New York Donation Z Removal Date Place Removed 6 and/or and/or Held H Hold Address N 2 Date Point of CO 0 Transportation Shipment G by Common Carrier Destination e E Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom }. Remains are Shipped,If Other than Above a Address CC LU 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/28/2021 Registrar of Vital Statistics qWert Andrew Curtis(ECectronicatly Signed) (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: I— Z Date of Disposition JO 17i 114 Place of Disposition �i_ ... .>tdr� LU (address) W En (section) (lot number) (grave number) O Name of Sexton or Person in Charge Premises /' A n a'}pLµtt O (p se print) Z f / LUTitle fi f ` Signature DOH-1555(07/18)p 1 of 2 • 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#