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Sanborn, Van Timothy NEW YORK STATE DEPARTMENT OF HEALTH Bu rial of Vital Records - Transit Permit Name First Middle Last Sex Van Timothy Sanborn Male Date of Death Age If Veteran of U.S.Armed Forces, 12/12/2021 64 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Kingsbury Town Street Address 1159 Farley Road,Kingsbury Town,New York 12839 V Manner of Death ©Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined Pending Circumstances Investigation 0 Medical Certifier Name Title Gerard Abess MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 25 IDBurial Date Cemetery,Crematory or Facility Name 12/14/2021 Pine View(Crematorium ❑Entombment Address X❑Cremation Queensbury Town,New York ElDonation c ❑Removal Date Place Removed H and/or and/or Held N Hold Address 0 Cl) 1-1 Transportation Date Point of p by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above a Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/14/2021 Registrar of Vital Statistics Cynthia A'Barclin(ECectronica1CySigned) (signature) District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ 4W Date of Disposition Z/f S II Place of Disposition 2 (ad ress) W CC CC (section) A (lot number) (grave number) SName of Sexton or Person in Charge of P ises �rh�^bw 1�r Z (p/e a print) W Signature Title 'ITN DOH-1555(07/18)p 1 of 2 1)15438 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 - 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#