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Chism, Jimmy Michael 15—) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jimmy Michael Chism Male Date of Death Age If Veteran of U.S.Armed Forces, 02/15/2022 62 Years War or Dates 1979-1995 Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p Mariner of Death © Natural Cause 1=1 Accident Ei Homicide 111 Suicide Undetermined 1'end11p Circumstances Investip<+lion W Medical Certifier Name Title Sean Bain MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 114 ❑Burial Date Cemetery,Crematory or Facility Name 02/18/2022 Pine View Crematory ❑ Entombment - Address X❑Cremation' Queensbury Town,New York l l Donation Z Removal Date Place Removed and/or and/or Held H Hold Address 0 d Date Point of Cl) ❑Transportation p by Common Shipment Carrier Destination n Disinterment Date Cemetery Address Date Cemetery Address n lieinterment 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 Remains are Shipped,If Other than Above Address CC a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/18/2022 Registrar of Vital Statistics Zoe Morgan(Electronically Signed) (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: Z Date of Disposition 21 I (2'Z Place of Disposition it.; 2 (address) W CC (section) (lot number) �} (g,,,v,'nun,bev) Name of Sexton or Person in Charge Premises - (ir t,�print) I (ple se print/ W Signature Cf.IA� - --- — - - Title ---- -�f DOH-1555(07/18)p 1 of 2 0 5802 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#