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Thieverge, Edward Arthur Sr. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Edward Arthur Thieverge Sr Male Date of Death Age If Veteran of U.S.Armed Forces, 01/20/2022 63 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Argyle Town Street Address 1149 County Rte 49,Argyle Town,New York 12834 LIJ p Manner of Death ©Natural Cause Accident Homicide Suicide ❑Undetermined Pending Circumstances Investigation WMedical Certifier Name Title C Frank Westad NP Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Argyle 5750 4 Burial Date Cemetery,Crematory or Facility Name 01/25/2022 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,New York ❑Donation Q ❑Removal Date Place Removed and/or and/or Held A Hold Address t' 0 n. Date Point of N ❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom }- Remains are Shipped,If Other than Above a Address C W EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/25/2022 Registrar of Vital Statistics Shelley.Mckernon(ECectronica1Ty Signed) (signature) District Number 5750 Place Argyle, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F Z Date of Disposition I BLSu� Place of Disposition Fut l,W1.� 11-0 W (address) W (section) (lot number" (grave number) 8 Name of Sexton or Person in Charge Premises 7/toi- 1' %1 Z lease print) W Signature Title (RMw� DOH-1555(07/18)p 1 of 2 `1 5 5 8 C 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#