Durham, Merrill NEW YORK STATE DEPARTMENT OF HEALTH*--‘ illr' # '3
Vital Records Section Burial - Transit Permit
lit ift
Name First
Middle Last Sex
Merrill Douglas Durham Male
iiig Date of Death Age `"''4f Veteran of U.S. Armed Forces,
01/23/2018 75 years War or Dates
Place of Death Hospital, Institution or
City, Tg®p(p- i Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
liti
Circumstances Investigation
at Medical Certifier Name Title
William Parker Physician
Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, T X X -XD(il4O( Glens Falls 5601 45
❑Burial Date Cemetery or Crematory
❑Entombment 01/29/2018 Pine View Cematory
Address
QCremation Queensbury, Ny
Date Place Removed
❑Removal _ and/or Held
anHd/or Address
� ' old
U
0 Date Point of
ti El Transportation Shipment
25 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
ir: Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home 01079
Address
82 Broadway Fort Edward, Ny
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
ilk
LEE
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/24/2018 Registrar of Vital Statistics iii0(signa~/
District Number 5601 Place Glens Falls;(N
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 lift Date of Disposition i/30 Ii4 Place of Disposition 1.+p
u 4-1 4<1°w
2 (address)
Ui
fil
CC (section) of number) (grave number)
p Name of Sexton or Person in Charge of emises , .�
J Ct
ice► (ple se print)
Signature _ Title _ a*roil'At
(over)
DOH-1555 (02/2004)