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Black Sr, Donald NEW YORK STATE DEPARTMENT OF HEALTH ' # (g Vital Records Section Burial - Transit Permit Name First Middle Last Sex Donald H. Black, Sr. Male Date of Death Age If Veteran of U.S. Armed Forces, November 29, 2017 86 War or Dates I— Place of Death Hospital, Institution or WCity, Town or Village Fort Edward Street Address 1085 Burgoyne Ave WManner of Death I771Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined 1-1 Pending Circumstances Investigation al Medical Certifier Name Title John Mongan, Dr. Address 6 Medical Park Ballston Spa, NY 12020 Death Certificate Filed District Number r1 Register Nu r City, Town or Village Fort Edward 69 5 ❑Burial Date Cemetery or Crematory November 30, 2017 Pine View Crematory 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z Ti Removal and/or Held and/or Address H Hold N Date Point of a ❑Transportation Shipment by Common Destination O Carrier Date Cemetery Address El Disinterment ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above MAddress W C' Permission is he eby granted to dispose of the humanv,a3ains descried above s indicated. Date Issued / Registrar of Vital Statistics k (signature) District Number 5'6.5 Place ' .1A7V C96 ic-0. /j Eth-)Wid I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 11/30/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W (section) (lot number) - (grave number) Name of Sexton or Person in Charge of :remises �Lt,4 a, Je wtC! (please print) W Signature G�-/ Title lR'Emt W (over) DOH-1555 (02/2004)