Sidusky, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John A. Sidusky Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 4, 2017 71 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address 219 Durkeetown Road
Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending
Ul
4.3 Circumstances Investigation
Medical Certifier Name Title
Robert Lemieux,
Address
219 Pope Hill Road Argyle, NY 12809
Death Certificate Filed District Number c -��6 Register Number
City, Town or Village Argyle /8.2
❑Burial Date Cemetery or Crematory
April 5, 2017 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queeisbury ,IY 12804
Date Place Removed
7 ❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
0 Carrier
_ ❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
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
F Remains are Shipped, If Other than Above
2 Address
W
0' Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued 41'5/J1 Registrar of Vital Statistics /.L) `Pt,& .,--
J (signature)
-' District Number 5 75 0 Place AvC (‹ , N l`
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui Date of Disposition 04/05/2017 Place of Disposition Quaker Road Queensbury,NY 12804
I (address)
at
te (section) x (lot number) (grave number)
Name of Sexton or Person in Charge of Premises /Xr ivr .)oin�l if
�I (please print)
U ': Signature L Title (
(over)
DOH-1555 (02/2004)