Ducharme, Myron Hubert NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
-Myron Hubert Ducharme Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/07/2019 82 Years War or Dates 1955-1961
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 35 Evergreen Lane 221,Queensbury Town,New York 12804
p Manner of Death
W FA Natural Cause Accident Homicide Suicide Undetermined Pending
U Circumstances Investigation
QW Medical Certifier Name Title
John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
--T --
City,Town or Village Queensbury 5657 181
Burial Date Cemetery,Crematory or Facility Name
12/09/2019 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
11 Donation
OZ Removal Date Place Removed
P and/or and/or Held
N Hold Address
O
Q- Date Point of
to Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
f.. Remains are Shipped,If Otherthan Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/09/2019 Registrar of Vital Statistics Caroline.9Yddegard Barger(EYectronicad Stgnea)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
WDate of Disposition IZ1/01) Place of Disposition
(address)
W
N
M (section) (lot number) c (grave number)
Name of Sexton or Person in Charge of Premises �s SHIN
Z / (Mase print)
W Signature /� �r Title ra VA—t 4(t
DO H-1555(07/18)p 1 of 2
•-
Public Health Law Sec. 4145(2b) ;
Receipt
Human remains of �' `' ' delivered on , 20
Pine View Cemetery Representing the funeral home named on,llurial permit
Official Funeral Directors Reg.or License# % '_