Doetsch, Francis lii
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Francis B. Doetsch Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 16, 2015 87 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Mathew Varughese M.D.
Address
100 Park St. Glens Falls NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls .S 60 ) 22/0
®Burial Date Cemetery or Crematory
April 20, 2015 Pine View Cemetery
0 Entombment Address
❑Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
a. by Common Destination
6; Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
;' Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ( (-7 (15 Registrar of Vital Statistics OCR. -W--A-^'
(signature)
District Number S 60 I Place C gas \\5 vi 9
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/20/2015 Place of Disposition Quaker Road Queensbury,NY 12804
I
(address)
Horicon 46G 1
(section) (lot number) (grave number)
11
Name of Se on or Person in Charge of Premises Connie L. Goedert
(please print)
Signature ilita, - ti� Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)