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Sprague Jr., John il NEW YORK STATE DEPARTMENT OF HEALTH ,r % s+g Vital Records Section Burial - Transit Permit vg, Name First Middle Last Sex John Edward Sprague Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, 4 : June 24, 2018 g7 War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address 144 Blackhouse Road Manner of Death a Natural Cause 0 Accident n Homicide 0 Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Robert Lemieux, Address 219 Pope Hill Road Argyle, NY 12809 A' Death Certificate Filed District Numbce51153 Register Number aer City, Town or Village Fort Edward 0 Burial Date Cemetery or Crematory June 26, 2018 Pine View Crematory 0 Entombment Address ' "';©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 0 Removal and/or Held and/or Hold Address Date Point of �a: 0 Transportation Shipment by Common Destination 41 Carrier UP Date Cemetery Address -x,e 0 Disinterment Reinterment Date Cemetery Address f' Permit Issued to Registration Number l Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 , Address ,q11,1 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom *' Remains are Shipped, If Other than Above Address u Permission is hereby ranted to dispose of the human s d` scri di,bv as dicated. c Date Issued Registrar of Vital Statistics V. (signature) District Number c.5125....5 Place 7Z(rn 1 t� � I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 3 Date of Disposition 06/26/2018 Place of Disposition Quaker Road Queensbury,NY 12804 " (address) (section) iii (lot number) (grave number) 3 Name of Sexton or Person in Charge of Premises /L r -Se,, 4` (please print) Signature 1 ,A- Title (14 e MK_ (over) DOH-1555 (02/2004)