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Pepin, John Louis - Z9 NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John Louis Pepin Male Date of Death Age If Veteran of U.S.Armed Forces, 09/08/2023 89 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 2 Fuller Road, Moreau Town,New York 12803 111 Manner of Death nUndetermined Pending � �Natural Cause Accident �Homicide Suicide I I � W Circumstances Investigation uJMedical Certifier Name Title CI John Quaresima MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 48 RBurial Date Cemetery,Crematory or Facility Name 09/11/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0• Removal Date Place Removed and/or and/or Held H Hold Address N 0 EL Date Point of U)nTransportation ES Common Shipment Carrier Destination Date Cemetery Address nDisintermentEI 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 F— Remains are Shipped,If Other than Above g Address CC W EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/11/2023 Registrar of Vital Statistics Brenda Niater(ElectronicallySigne4 (signature) District Number 4562 Place Town Of Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition I lZ j j Place of Disposition �,,,,1 s— � tom._ IJJ 2 (address) W N IX (section) 11(tot number) (grave number) • Name of Sexton or Person in Charge of Pr i s 117- Z ((ase print) tL Signature Title 2MAI DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt , Human remains of delivered on ' ` , 20 -- , , r J.', --'./. i .47 - La-,7:,-'`,„_. , - ------•''' n',- ' Pik View Cemetery Representing the funeral home tamed on burial permit Official Funeral Directors Reg.or Licene# ' i , .