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McDougall, Robert tl70: 7 ` NEW YORK STATE DEPARTMENTpF°MEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Robert Perley McDougall _ Male Date of Death Age If Veteran of U.S. Armed Forces, May 29, 2018 69 War or Dates Place of Death Hospital, Institution or g City, �}QC,� ow or Village 1 Street Address 13 Perley Lane W Manner of Death E Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending Circumstances Investigation M` Medical Certifier Name Title William Parker, Dr. Address 48 East Street Fort Edward, NY 12828 Death Certificate Filed District Number Register Number C City, Town or Village -is0 ❑Burial Date Cemetery or Crematory May 30, 2018 Pine View 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address p. Hold a Date Point of „.❑Transportation Shipment (a. by Common Destination O Carrier Date Cemetery Address III Disinterment Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077 Address 123 Main St., Argyle NY 12809 Name of Funeral Firm Making Disposition or to Whom tt Remains are Shipped, If Other than Above • Address Lira w E.' Permission is h reby granted to dispose of the human remains described above as indicated. Date Issued S 30 / 3 Registrar of Vital Statistics tU 1 jf �J ,,,� J (signature) District Number 5 750 Place Alegi/I.r, k. y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition 05/30/2018 Place of Disposition Quaker Road Queensbury,NY 12804 X (address) 111 tinti (section) �I (lot number)) (grave number) ,' Name of Sexton or Person in Charge of Pre ises ^a Y . )�A �(please print) W Signature 0 Title MEMITDrL T (over) DOH-1555 (02/2004)