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Seeley, Terry Robert z.f) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Per it Bureau of Vital Records Name First Middle Last Sex Terry Robert Seeley Male Date of Death Age If Veteran of U.S.Armed Forces, 02/17/2023 82 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation W h Manner of Death �Natural Cause Accident ElHomicide ESuicide FlUndetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title Kenneth France MD Address 170 Warren St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 93 Burial Date Cemetery,Crematory or Facility Name 02/21/2023 Pine view crematory Entombment Address ©Cremation Queensbury Town,New York Donation ZZ 71 Removal Date Place Removed and/or and/or Held H Hold Address N O CI. Date Point of t/) Transportation Shipment p by Common Carrier Destination ElDisinterment Date Cemetery Address Reinterment 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 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/21/2023 Registrar of Vital Statistics 9Kegan No(in(ECectronica((ySigned) (signature) District Number 5601 Place City Of Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition 2I7z(L3 Place of Disposition 2 (address) W NCC (section) /!ot number) (grave number) G Name of Sexton or Person in of Premises "Ai (pleaseZ (please print) W Signature Title rim vie DOH-1555(07/18)pi of 2 Public Health Law Sec. 4145(2b) 1 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#