Deyoe, Nathan f b
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Nathan J Deyoe Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 28, 2017 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Washington Center
W Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri 1-1 Pending
CircumstancesInvestigation
W Medical Certifier Name Title
0 Edit Masaba, MD Dr.
Address
35 Gilbert Street Greenwich, NY 12834
Death Certificate Filed District Number Register Number
City, Town or Village Argyle 5.15Q Is
❑Burial Date Cemetery or Crematory
May 30, 2017 Pine View Crematory
❑Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri❑ Removal and/or Held
and/or Address
p Hold
Date Point of
a. Transportation Shipment
Vil 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-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
W
a. Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued Sig(,) Registrar of Vital Statistics `' ^A'
(signature)
District Number 515 v Place pv-5 rtki
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tJJ; Date of Disposition 05/3 f/2017 Place of Disposition Quaker Road Queensbury,NY 12804 )9e 0ZZ cre i,c4
X (address)
CO
(section) (lot nymber) (grave number)
pName of Sexton or,Per�so C arge of Premises �'^ I ✓t ]t�4J�1 C'Li e
Z //( (please print)
. Signature ( G Title �- rn 4-lo
i'
(over)
DOH-1555 (02/2004)