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Crouser, Bruce Terry it 1 Li NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Bruce Terry Grouser Male Date of Death Age If Veteran of U.S.Armed Forces, 02/23/2022 79 Years War or Dates 1_ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation Manner of Death Undetermined Pending 111 © Natural Cause EI Accident Homicide ❑Suicide Circumstances Investigation W Medical Certifier Name Title CI Jean Flanagan MD Address 170 Warren St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 124 Burial Date Cemetery,Crematory or Facility Name 02/24/2022 Pine View Crematory 0 Entombment Address X❑Cremation Queensbury Town,New York ❑Donation ❑Removal Date Place Removed and/or and/or Held H asHold Address 0 d 1-1 Date Point of U) ❑Transportation by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ElReinterment 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 H Remains are Shipped,If Other than Above g Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/24/2022 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: WDate of Disposition 217 S 11') Place of Disposition 41 2 (address) W W (section) ,/j(/otnimber) (grave number) 0 Name of Sexton or Person in Charge of Premi �' Lc. v1A41't (please riot) Title W Signature v/00-70 f� DOH-1555(07/18)p t of 2 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#