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Morrison, Schwartz Otis - /IO3 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Schwartz Otis Morrison Male Date of Death Age If Veteran of U.S.Armed Forces, 12/21/2021 65 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 35A Skylark Drive, Moreau Town,New York 12803 W `p Manner of Death © Natural Cause 0 Accident El Homicide El Suicide El Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title CI John Lukaszewicz MD Address 101 Ridge Street 2,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 63 0 Burial Date Cemetery,Crematory or Facility Name 12/23/2021 Pine View Crematory 0 Entombment Address ElCremation Queensbury Town,New York Donation 0 El Removal Date Place Removed and/or and/or Held F Hold Address (/) 0 a. Date Point of U) 11 Transportation p 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-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom 1-- Remains are Shipped,If Other than Above N Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/22/2021 Registrar of Vital Statistics Geeann ,fc ca6e(Electronically Signed) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: `J /a Z Date of Disposition 'f f' Place of Disposition 47i�Yt4- L rktOr_-- W 2 (address 11,113174 W NCC (section) / (lot number) (grave number) I/ 8 Name of Sexton or Person in Charge of Premises GA as .�QAn t if Z /plea a print/ W Signature Title 6-' _ DOH-1555(07/18)p 1 of 2 n 54 82 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 Directois Reg. or License#