Roberts, Paul NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Paul George Roberts Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 19, 2017 78 War or Dates
Place of Death Hospital, Institution or
LU City, Town or Village Queensbury Street Address 43 Cottage Hill Road
12 Manner of Death Natural Cause 0 Accident ❑ Homicide ESuicide 0 Undetermined El❑ Pending
Ill
U. Circumstances Investigation
Medical Certifier Name Title
Thomas Coppens, Dr.
Address
3 Iron Gate Center Glens Falls 12801
Death Certificate Filed t.trItly,i5ber nkr Number
City, Town or Village Queensbury
®Burial Date Cemetery or Crematory
May 23, 2017 Pine View Cemetery
Q Entombment Address
a;LiCremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
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
Remains are Shipped, If Other than Above
Address
IX
Lit
CL Permission is hereby granted to dispose of the human ins described ove as indicated.
Date IssueclS10 t) Registrar of Vital Statistics
�-- C2? n��
- --
(signature)
District Number
") Place /Qc s .r1 a'r -6c_t_as),..s, ---
I certify that the remains of the decedent identified above were disposed of in acconce with th' permit on:
Date of Disposition 05/23/2017 Place of Disposition Quaker Road Queensbury,NY 12804
X e7 (address
Ili
', ( tion) (lot number) (grave number)
Name of Sexto or Person in Charge of Premises ti4./t0,tst6 6tft
�D ) (please ' t
Signature /�- Title
i
(over)
DOH-1555 (02/2004)