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Chhim, Anthony Achariya Z NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Anthony Achariya Chhim Male Date of Death Age If Veteran of U.S.Armed Forces, 12/28/2021 36 Years War or Dates F- Place of Death Hospital,Institution or W City,Town or Village Suffern Village Street Address Good Samaritan Hospital Of Suffern `p Manner of Death © Natural Cause El AccidentHomicide ❑Suicide Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title O Fatemeh Moslehi MD Address 255 Lafayette Ave,Suffern Village,New York 10901 Death Certificate Filed District Number Register Number City,Town or Village Suffern Village 4329 497 ElBurial Date Cemetery,Crematory or Facility Name 01/03/2022 Pine View Crematory ElEntombment Address Cremation Queensbury Town,New York ElDonation Removal Date Place Removed Li"and/or and/or Held Hold Address 0 CL Date Point of Cl) LI Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address El 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 F. Remains are Shipped,If Other than Above 2 Address C W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/30/2021 Registrar of Vital Statistics Lynne Bryant(ECectronica1TySigned) (signature) District Number 4329 Place Suffern Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F— WDate of Disposition 122. Place of Disposition 2 (a ress) W CC N (section) (lot number) cimi (grave number) 2 Name of Sexton or Person in Charg Premises i�ti' { 0 (ple a print) Z W Signature Title 0111 DOH-1555(o7/18)p i of 2 L) 1, fl Public Health Law Sec. 4145(2b) Receipt Human remains of " k delivered on ' C\ , 20 -/ ,A. / " Pine View Cemetery Represent tig the funeral home named on burial permit Official Funeral Directors Reg.or License# ��`?,