McCane, Daniel NEW YORK STATE DEPARTMENT OF HEALTH #, y 4530
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
li Daniel Melvin McCane Male
Date of Death Age If Veteran of U.S. Armed Forces,
5 November 20, 2018 59 War or Dates
Place of Death ,` Hospital, Institution or
City, Town or Village Fort Ann t\GkoC Street Address 76 Country Lane
Manner of Death X❑Natural Cause ❑ Accident 0 Homicide D Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
- Medical Certifier Name Title �1
Mackenzi Evangelist, M D
Address 13 NEt-J S(bilk 9 t\U L Mai\1' (Z to g
.: Death Certificate Filed �� District Nut S 1 Register tl%ber
;4,. Ci , Town or Village Fort Ann C�
❑Burial Date Cemetery or Crematory
November 21, 2018 Pine View Crematory
.- u Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed _.
Removal and/or Held
and/or Address
Hold
Date Point of
. ❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
1 Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he eby g Tted to dispose of the human remain d scriSedd abo i. •icat•d./La_
Date Issued I t �I t Registrar of Vital Statistics V�����
, _ _.0. [....(10 ..stiptg, 1
District Number n \ Place t C3 W't\ D
r I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
; : Date of Disposition 11/21/2018 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises C `Nig Se AA I'W
(pl se print)
Signature if /6-- Title fir '0.ii—
(over)
DOH-1555 (02/2004)