Myott, Dennis NEW YORK STATE DEPARTMENT OF HEALTH*Vital Records Section V Burial - Transit Permit
Name First Middle Last Sex
Dennis Michael Myott Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. January 5, 2006 52 War or Dates
Z Place of Death Hospital, Institution or
City,Town, or Village Argyle Street Address Residence
0 Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
Circumstances Investigation
() Medical Certifier Name Title
Dr. Robert Sponzo Dr.
Address
102 Park St. , Glens Falls, NY 12801
Death Certificate Filed District Number 5,2 Register Number
City,Town or Village Argyle
❑Burial Date Cemetery or Crematory
January 9, 2006 Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
Hold
Date Point of
4 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
5 ❑ Disinterment
❑ Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01140
Address
123 Main St. , Argyle, New York 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
W Address
0
Permission is herby grantedf to dispose of the human rem i described ab a indicated.
Date Issued '/ O(o Registrar of Vital Statistics rem
���`
/ (signature)
District Number S 11 Place Argyle,New York
tr I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 01/09/2006 Place of Disposition Pine View Crematory
2 (address)
W
(section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises IA !Z i-( (.
Z (please print)
W �v1 CQ�Z. 4 i Title C� f` tom-+O
Signature (
(over)
DOH-1555 (02/2004)