Thevis, George Michael # �31
O F HEALTH II 1.----.7"---).1-.
�
NEW YeRKSTATE DEPARTMENTBurial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George Midhael Thevls Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/29/2022 68 Years War or Dates
Place of Death Hospital.Institution or
City,Town or Village Wilmington Town Street Address 5239 State Route 86•Wmlngton Town,New York 12996
G
Manner of Death El JAccidentHomicide Suicide ❑Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Jay Heald Coroner
Address
7521 Court Street,Elizabethtown Town,New York 12932
Death Certificate Filed Town of Wrylmtngton District Number Register Number
Cit ,Town or Village 1567
Burial Date Cemetery,Crematory or Facility Name
10/191
2022 Pine View Crematory
Entombment Address
Cremation Clueensbury Town,New York
Donation
❑and/or Removal Date Place Removed
and/or Held
I—
(7) Hold Address
0 Date Point of
0)❑Transportation Shipment
p by Common Carrier Destination
Disinterment
Date Cemetery Address
El Re interment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Khmer 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
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/19/2022 Registrar of Vital Statistics Dawn Stevens{Tc'lmmrea9 SO4
(s/gnatne)
District Number 1567 Place Town Of Wilmington
I certify that the remains of the decedent identified above were disposed of in accordance with this permiton:
W• Date of Disposition I O I/o1 Z2 Place of Disposition i•u(address) 4.e...... .._
W
f/1CC (sectac»i gat nu /gra ar numbed
lit
O• Name of Sexton or Person in Charge of P mises (Please�
W i ,:� Title � 611�4��t�
Signature
DOH-1555(o7/18)p 1 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#