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Irwin, Samuel Francis Dl O NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Samuel Francis Irwin Male Date of Death Age If Veteran of U.S.Armed Forces, 11/24/2021 66 Years War or Dates ▪ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital Manner Death CIof © Natural Cause El Accident El Homicide El Suicide Ei Undetermined El Pending W Circumstances Investigation U O Medical Certifier Name Title Aaron Heckler PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 543 ElBurial Date Cemetery,Crematory or Facility Name 11/29/2021 Pine View Crematory Entombment Address Cremation Queensbury Town, New York Donation Removal Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of U) Li Transportation O by Common Shipment 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 �.- Remains are Shipped,If Other than Above 2 Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/26/2021 Registrar of Vital Statistics Rp6ertAndrew Curtis(ECectronica1Ty 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: Z Date of Disposition Zpl(Place of Disposition 397` p tJ tv.k3 efy4vtLIU (address) uJ fE (section) (lot number) (grave number) aName of Sexton or Person in Charge of Premise Y14� ►►1 br)� Da`' Z o n (please print) lL Signature / Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) U , $,, I Receipt Human remains of delivered on , 20 ! ` Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#