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Crosse, Jeffery Edward , c)NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeffery Edward Crosse Male Date of Death Age If Veteran of U.S.Armed Forces, 11/07/2023 58 Years War or Dates 1._ Place of Death Hospital,Institution or Z City,Town or Village Greenwich Town Street Address 3 Green Street,Greenwich Town,New York 12834 UJ n • Manner of Death n Natural Cause Accident Homicide Suicide Undetermined ❑Pending V I 'Circumstances Investigation IJJ Medical Certifier Name Title O Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed Town Of Greenwich District Number Register Number City,Town or Village 5757 21 HBurial Date Cemetery,Crematory or Facility Name 11/13/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held l Hold Address N 0 O. Date Point of Cl)❑Transportation Q by Common Shipment Carrier Destination Disinterment 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 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/12/2023 Registrar of Vital Statistics Deb-orait Tjarkrgkctronicaiiy*n4 (signature) District Number 5757 Place Town Of Greenwich I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition If(I3 J13 Place of Disposition "rtiC 6AA Cl'kf'PF. W 2 (address) UJ CO CC (section) ILIML- Blot number) (grave number) O Name of Sexton or Person in Charge ises �h Zafease print/ Ill Signature Title < �n��Y DOH-1555(07/18)p 1 of 2 L Public Health Law Sec. 4145(2b) F, Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#