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Suprise, George Mark eill NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex George Mark Suprise Male Date of Death Age If Veteran of U.S.Armed Forces, 03/19/2023 67 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village South Glens Falls Village Street Address 47 Harrison Avenue,South Glens Falls Village,New York 12803 W Manner of Death Undetermined Pending W Natural Cause Accident Homicide Suicide g ✓ Circumstances Investigation W Medical Certifier Name Title G Eugene Ladue Coroner Address 31 Woodlawn Ave.,Saratoga Springs,New York 12866 Death Certificate Filed Village Of South Glens Falls District Number Register Number City,Town or Village 4524 6 Burial Date Cemetery,Crematory or Facility Name 03/23/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation o❑Removal Date Place Removed and/or and/or Held F Hold Address CO 0 d Date Point of U) Transportation Shipment Cl by Common Carrier Destination Date Cemetery Address Disinterment • 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 l~ Remains are Shipped,If Other than Above "a Address CC LU 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/22/2023 Registrar of Vital Statistics Samantha Berg(Electronically 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 3173 I73 Place of Disposition '(41a,V,_ W (address) 2 uJ U)CC (section) (lot number) sw.t (grave number) g Name of Sexton or Person in Charge of Premises Arr,1pl'' (� (please print) uJ Signature Z. Title 7 `i")ifit7t DOH-1555(o7/i8)p 1 of 2 Public Health Law Sec. 4145(2b) f 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#