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Francis, Russell Ross 7c ) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Russell Ross Francis Male Date of Death Age If Veteran of U.S.Armed Forces, 10/01/2023 70 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village North Elba Town Street Address 27 Airport Lane,North Elba Town,New York 12946 W Manner of Death g � �Natural Cause Accident n Homicide Suicide I-(Undetermined �Pending W Circumstances Investigation V W Medical Certifier Name Title CI Jay Heald Coroner Address 37 Hillman Lane,Lewis Town Essex,New York 12950 Death Certificate Filed Town Of North Elba District Number Register Number City,Town or Village 1560 81 Burial Date Cemetery,Crematory or Facility Name 10/03/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York nDon Wig n 0Z Removal Date Place Removed and/or and/or Held N Hold Address 0 a. Date Point of N❑Transportation Shipment by Common Carrier Destination nDisinterment 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 S Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/03/2023 Registrar of Vital Statistics Laurie Curtis Dudley(Electronic-a*Signee9 (signature) District Number 1560 Place Town Of North Elba I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Ih- Z Date of Disposition I o l y l z3 Place of Disposition �L//fcf/r CPwlTOi'r,I. 11.1 2 (address) W CCCC (section) // (lot number) (grave number) a Name of Sexton or Person in Charge of Premises 4 V` w if lease print) Z a �T" W Signature Title DOH-1555(07/18)p t of 2 7340 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#