Daniels, Daxson lir
I sz(
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section k Burial - Transit Permit
Name First Middle Last Sex
Daxson John Daniels Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 8, 2018 L M War or Dates
Place of Death Hospital, Institution or
it a City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death❑Natural Cause ❑ Accident El Homicide ❑ Suicide ❑ Undetermined m Pending
Circumstances Investigation
3 Medical Certifier Name Title
Terry Comeau,
Address
1340 State Route 9 Lake George, NY 12845
Death Certificate Filed District Number Register NumberL)
g.
City, Town or Village Glens Falls �.J
0 Burial Date Cemetery or Crematory
October 15, 2018 Pine View Crematory
❑Entombment Address
-_ ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
el Hold
Date Point of
4▪ ❑Transportation Shipment
Ott by Common Destination
O Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El 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
5> Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i 1) I i 2(-2.0 t Registrar of Vital Statistics )0-y-e
(signa ure)
District Number 5b1 ) Place 6 Is2/v..S I1s /Jy
, `
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 10/15/2018 Place of Disposition Quaker Road Queensbury,NY 12804
Z (address)
W
EC (section) lot number) (grave number)
Name of Sexton or Person in Charge of Premises �n.�ok.." �AA li
>L
(please print)
Signature It / Title Arensiroa,
(over)
DOH-1555 (02/2004)