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Bourque, David— i _ A 09 N EW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex David Paul Bourque Male Date of Death Age If Veteran of U.S. Armed Forces, 09/24/2019 83 Years War or Dates 1955-1958 Place of Death Hospital, Institution or WCity, Town or Village Argyle Town Street Address 1653 County Route 49 Route, Argyle Town, New York 12809 p Manner of Death © Natural Cause ❑ Accident Homicide Suicide Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title Paul Filion MD Address 3 Irongate Center, Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Argyle 1 5750 38 ❑ Burial Date Cemetery, Crematory or Facility Name 09/30/2019 Pine View Crematory Entombment Address FRI Cremation Argyle Town, New York 11 Donation Date Place Removed OZ Removal and/or and/or Held ~ Hold Address N O a Date Point of to Q Transportation by Common Shipment ----- Carrier Destination Disinterment Date Cemetery Address 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, New York 12809 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Otherthan Above !� Address IX: W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/30/2019 Registrarof Vital Statistics Shelley Mckernon (Electronically Signed) (signature) District Number 5750 Place Argyle, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ZW Date of Dispositiong I3o i Iq Place of Disposition j`�ig t �`q LU (address) W N _ (section/ t number/ (grave number) A gName of Sexton or Person in Charge of Premises t� � �tT /P/ea print/ z W Signature �///(/ Title DOH-1555 (o7/18) p 1 of 2 Public Health Law Sec. 4145(2b) 012564 Receipt Human remains of Pine View Cemetery Official delivered on 20OA Representing the funeral home named on urial permit Funeral Directors Reg. or License # 44