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Vogt, Paul NEW YORK STATE DEPARTMENT OF HEALTH 1 C13y Vital Records TransitPer 1 co ds Section Burial e t Name First Middle Last Sex Paul Julius Kennedy Vogt Male Date of Death Age If Veteran of U.S. Armed Forces, December 3, 2017 53 War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address 25 McIntyre Street Manner of Death X❑Natural Cause ❑ Accident E Homicide 0 Suicide ❑ Undetermined El Pending Circumstances Investigation 111 Medical Certifier Name Title William Parker, Dr. Address 48 East Street Fort Edward, NY 12828 Death Certificate Filed District Number Register Nkmber City, Town or Village Fort Edward 5r7 ' ❑Burial Date Cemetery or Crematory December 6, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address F Hold tO Date Point of ❑Transportation Shipment by Common Destination 5 Carrier F ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address 4 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 gro.2 Address Lli a Permission is her by ranted to dispose of the human e "ns describe ab ve s ' dicated. Date Issued Registrar of Vital Statistics (signature) District Number 5755 Place tv-W-,1 ( L ( � EdWa/ 1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 12/06/2017 Place of Disposition Quaker Road Queensbury,NY 12804 W (address) tie (section) ��(lot number) (grave number) aName of Sexton or Person in Charge of Pre ises .;, iM al (p ase print) Signature K' Title (grful o_ (over) DOH-1555 (02/2004)