Protchett, Cortez Demetrius NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cortez Demetrius Pritchett Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/24/2021 46 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 191 Corinth Road 204,Queensbury Town,New York 12804
Manner of Death ElNatural Cause E Accident ❑Homicide Suicide Undetermined NIPending
VCircumstances Investigation
W Medical Certifier Name Title
CI Lynn Keil PA
Address
1340 State Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 248
❑Burial Date Cemetery,Crematory or Facility Name
12/28/2021 Pine View Crematory
Entombment Address
- a Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
- Hold Address
O
G. Date Point of
t!) ❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
El Disinterment
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
Il— Remains are Shipped,If Other than Above
' Address
CC
W
0' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/27/2021 Registrar of Vital Statistics Caroline'fil tegarde Barber(EtectronicaltySigned)
(signature)
District Number 5657 Place Queensbury, 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 1 .—;cq-�-� Place of Disposition f),P' V ,/ C,ft"(41'fY
W
2 (address)
W
CC CC (section) (lot number) (grave number)
tiu
0 Name of Sexton or Person in Charge of Premises ' ,SR'%r`✓
(please print)
!L Signature ✓ Title �/ Wel>r
DOH-1555(07/18)p 1 of 2
* i )1 5 fit
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#