White,Arthur T 4;11 #li) 1 1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records t
Name First Middle Last Sex
Arthur T White Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/08/2022 65 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village IPloreau Town Street Address 163 Reservoir Road,Moreau Town,New York 12828
ILI
p Manner of Death El Natural Cause nAccident Homicide ESuicide 7Undetermined El Pending
LU I I'Circumstances ff ''Investigation
U
W Medical Certifier Name Title
a Mark Quaresima MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 44
RBurial Date Cemetery,Crematory or Facility Name
08/10/2022 Pine View Crematory
Entombment Address
Cremation Queensbury own,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold `Address
U)
0
n. Date Point of
Cl)❑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-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
N Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/09/2022 Registrar of Vital Statistics Geeann 94cCa6e(ECectronicalTy Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH
Z Date of Disposition Ql�l I it Place of Disposition 'i stL_ t
W
2 (address)
W
CC N (section) /1 r+' �-
(lot number) (grave number)
0 Name of Sexton or Person in Charge
/z
(case print)
W Signature � y� Title ll60 fri rue
DOH-1555(o7/18)p 1 of 2
1 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#