Burlett, Paul William NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Paul William Burlett Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/01/2022 68 Years War or Dates 1972-1978
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death XINatural Cause El Accident ❑Homicide ElSuicide ElUndetermined ElPending
C) Circumstances Investigation
0LU Medical Certifier Name Title
Abigail Macomber PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 74
▪Burial Date Cemetery,Crematory or Facility Name
02/03/2022 Pine View Crematory
Entombment Address
O Cremation Queensbury Town,New York
▪Donation
Date Place Removed
O El Removal
and/or and/or Held
- Hold Address
a Date Point of
to1..1 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-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/02/2022 Registrar of Vital Statistics 9Kegan Nolin(ECectronica1TySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ y v i� )orY
Z Date of Disposition �� � Place of Disposition /�'he. Cita
�c,
W
(address)
W
N
CC (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises �Q,rm Ly EfAirL
Z (please print)
W Signature Title Orkin°i0C
DOH-1555(07/18)p 1 of 2
f"�
1 1 (1 3
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#