Himerick, John Elmer Jr. Mgr
NEW YORK STATE DEPARTMENT OF HEALTH s Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Elmer Himelrick Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/20/2023 79 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Wilton Town Street Address 4 Andover Avenue,Wilton Town, New York 12831
W Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide
Circumstances Investigation
C.) Medical Certifier Name Title
Zachary Novakovic DO
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed Town Of Wilton District Number Register Number
City,Town or Village 4569 8
Burial Date Cemetery,Crematory or Facility Name
01/24/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
- and/or and/or Held
- Hold Address
0
CI. Date Point of
U)❑Transportation
p by Common Shipment
Carrier Destination
O
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
1— Remains are Shipped,If Other than Above
5 Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/24/2023 _ Registrar of Vital Statistics Susan(Ba&dwin(ECectronicaffy Signed)
(signature)
District Number 4569 Place Town Of Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-�Z Date of Disposition /IZC I23 Place of Disposition � L 4r7�L_
2 (address)
W
NCC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises It
�i
Z (p ase print)
WrytnlIW
Signature - Title Cit
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) ` "` s
Receipt
Human remains of i ( delivered on
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#