Rabine, David NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section a
Name First Middle Last Sex
David Joseph i Rabine Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 12, 2017 64 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 3 Blvd Street#108
Manner of Death❑Natural Cause ❑ Accident ❑ Homicide E Suicide ❑ Undetermined ri❑ Investigation
Pending
W Medical Certifier Name Title Circumstances
Robert Lemieux,
Address
219 Pope Hill Road Argyle, NY 12809
Death Certificate Filed District NumberRegister Number
City, Town or Village Hudson Falls 5' 10 I S
❑Burial Date Cemetery or Crematory
July 14, 2017 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
g. ❑
Removal and/or Held
and/or Address
E Hold
011 Date Point of
p, El Transportation Shipment
0 by Common Destination
G Carrier
❑ Disinterment Date Cemetery Address
ElReinterment 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
Remains are Shipped, If Other than Above
Address
d" Permission is hereby granted to dispose of the human remains cr ed above as indicated.
Date Issued 7- Pi _a 01 7 Registrar of Vital Statistics „�i:;__.Cxi-12.91-e-r Q-----
(signature)
District Number S"'aV Place .11 .:Alic,t_t vL0—_
___
II certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/14/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) l(lot number) (grave number)
Name of Sexton or Person in Charge of remises art Slitt
z► (p a se print)
Signature i .17 Title tilfrOf Pet
(over)
DOH-1555 (02/2004)