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Mondoux Jr., William NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Per it Name First Middle Last Sex William Joseph Mondoux Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, December 29, 2018 92 War or Dates Place of Death Hojpital, Institution or m City, Town or Village Moreau ,treet Address Home of The Good Shepherd 0 Manner of Death X❑Natural Cause ❑ A I Homicide Suicide 1-1 Undetermined Pending Circumstances Investigation Medical Certifier Name Title T -4 as Coppens, Dr. • A. -ss ron Gate Cent Glen 801 Death Certificate Fi � d. - rict Number Register Number City, Town or Villa, -• �512 �' ❑Burl Da = • Cemetery or Crematory Aece ber 31, 2018 Pine View Crematory ---DEntombment Address ©Cremation Quaker Ronsbury,NY 12804 -Banal► +fie' Place Removed t 1-1 Removal and/or and/or Held p. Hold Address Date Point of i 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 I l# CL Permission is hereby granted to dispose of the human re describe ��b a as indicated. Date Issued / 3 1420 c� Registrar of Vital Statistics /DA /� ��" �f ` t (sigrYafure) District Number �g; Place S l f li5 f el )ç1iiw7 /q /aYA2 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: wDate of Disposition 12/31/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) 11 IX (section) Ii(lot number) (grave number) a 111 Name of Sexton or Person i Charge of Pre ises Ai ��N (please print) In Signature Title ( Q,. (over) DOH-1555 (02/2004)