Hart, Burdette Carl # ,,,,
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NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Burdette Carl Hart Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/30/2023 86 Years War or Dates 1954-1957
F Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 32 Clements Road,Queensbury Town, New York 12804
ILI
/3 Manner of Death []NaturalCause []Accident Homicide []Suicide []Undetermined ❑Pending
W
U II 'Circumstances Investigation
W Medical Certifier Name Title
CI John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 83
Burial Date Cemetery,Crematory or Facility Name
06/01/2023 Pine View Crematory
[]Entombment Address
[]Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
O. Date Point of
CO OTransportation
p by Common Shipment
Carrier Destination
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Disinterment
Date Cemetery Address
Date Cemetery Address
[]Reinterment
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
I— 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 06/01/2023 Registrar of Vital Statistics Caroline X garareBarGer(fElctronically,Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition /IZ 173 Place of Disposition .P,,..v,,__ 6a--_..
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g (address)
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CC (section) (lot number) (grave number)
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Name of Sexton or Person in Charge f Premises L
Z (please print)
tL Signature Title fi�r�t4 7
DOH-1555(07/18)p 1 of 2
1..701
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# ;:, ,_ ,'
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