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Wolfe, Paul John NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Vs- Bureau of Vital Records Name First Middle Last Sex Paul John Wolfe Male Date of Death Age If Veteran of U.S.Armed Forces, 11/07/2019 74 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Kingsbury Town —7Street Address 12 Tenth Avenue,Kingsbury Town,New York 12839 Q Mannerof Death © Natural Cause Accident Homicide Suicide Undetermined Pending U Circumstances Investigation LU Medical Certifier Name Title Umbreen Rozell MD Address 100 Park Street,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Kingsbury Town 5762 15 Burial Date Cemetery,Crematory or Facility Name 11/12/2019 Pine View Crematory Entombment Address 0 Cremation Queensbury Town,New York Donation Z Date Place Removed 0 Removal and/or and/or Held ~N Hold Address O IL N ❑Transportation Date Point of p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped,If Other than Above g Address Lu (L Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/08/2019 Registrar of Vital Statistics CynthiaA Bardin(ECectronicallySigned) (signature) District Number 5762 Place Kingsbury Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition it 12 I Iy Place of Disposition 2 (address) W M (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of P mises L .�nl Z /p ase print/ W Signature � Title DO H-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 -1307 Receipt Human remains of ''I _ � �' delivered on `, 20 Pine View Cemetery Representing the ftiner4Tt home named on burial permit Official Funeral Directors Reg.or License#