Cleveland, Steven Howard (Th # (067
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NEWYORKSTATEDEPARTMENTOFHEALTH
Bureau of Vital Records �..� Burial - Transit Permit
Name First Middle Last Sex
Steven Howard Cleveland Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/15/2022 60 Years War or Dates
H Place of Death Hospital,Institution or
111
Z City,Town or Village South Glens Falls Village Street Address 129 Saratoga Avenue 246,South Glens Falls Village,New York 12803
Q Manner of Death Natural Cause ccident I l Homicide Suicide n Undetermined
W A n Pending
C.) f� I(Circumstances II ''Investigation
CI
Medical Certifier Name Title
Susan Hayes-Masa Coroner
Address
40 McMaster Street,Ballston Spa Village,New York 12020
Death Certificate Filed Village Of South Glens Falls District Number Register Number
City,Town or Village 4524 5
BurialEd
Date Cemetery,Crematory or Facility Name
08/19/2022 Pine View Crematory
Entombment Address —"—
IlCremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
d. Date Point of
Cl) Transportation
p by Common Shipment
Carrier Destination
oDisinterment Date Cemetery Address
ElReinterment 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
1— Remains are Shipped,If Other than Above
5 Address
CC
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/19/2022 Registrar of Vital Statistics Samantha Berg(ECectronicalty Signed)
(signature)
District Number 4524 Place Village Of South Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition g I li(It. Place of Disposition
,._ 4---,.._
2 (a ress)
W
Cl)
CC (section) (lot number (grave number)
0 Name of Sexton or Person in Charge Premises G L
�
`Z (please print)
Signature � Title /� �/81�
Lug
DOH-1555(07/18)p 1 of 2
1 I
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1 Public Health Law Sec. 4145(2b) �'67
1 1
Receipt
1 Human remains of delivered on ' , 20
1
1 Pine View Cemetery Representing the funeral home n:med on burial permit
1 Official Funeral Directors Reg.or Licens- #