Balzer, Edward 11111
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Edward Balzer Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/07/2022 73 Years War or Dates
f. Place of Death Hospital,Institution or
WCity,Town or Village Lake Luzerne Town Street Address 25 Northwoods Road, Lake Luzerne Town, New York 12846
p Manner of Death El Natural Cause Accident El Homicide Suicide Undetermined ❑Pending
(Wj Circumstances Investigation
QMedical Certifier Name Title
Lynn Keil PA
Address
1340 State Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Lake Luzerne District Number Register Number
City,Town or Village 5656 8
Burial Date Cemetery,Crematory or Facility Name
04/09/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 ElRemoval Date Place Removed
and/or and/or Held
Hold Address
N
0
a Date Point of
Cl)❑Transportation
p by Common Shipment
Carrier Destination
D Cemetery Address
isinterment Date
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500, Lake Luzerne, New York 12846
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
5 Address
Cr
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/08/2022 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed)
(signature)
District Number 5656 Place Town Of Lake Luzerne
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
'/
z Date of Disposition (/ zo7t Place of Disposition , e V;e� C(`e/!t 4-1,
(address)
W
CC N (section) 2umb1 (grave number)
0 Name of Sexton or Person in Charge Prem. es f/�i9N�
`- ,.,(please print)
s--
W Signature � Title ow" `_
DOH-1555(07/18)p 1 of 2
r . rz(
;$lb V SI, u°
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#