King, Daniel $ 139
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section t t Burial - Transit Permit
Name Da rri el Mi ldle Last KING Sex
Male
Date of Death Age If Veteran of U.S. Armed Forces,
1 1 -5-201 7 60 War or Dates no
Place of Death Hospital, Institution or
City, Town or Village Chestertown Street Address 264 Stagecoach Rd.
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Paul Bachman M.D.
Address
Warrensburg, NY
fiX Death Certificate Filed District Number Register Number
City, Town or Village Chestertown SO 5-.D. a 0
Date1 1 /7/201 7 Cemetery or Crematory
�� ❑Burial
❑Entombment Pine View Crematory
Address
®Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
km- Permit Issued to Miller Funeral Home Registration Number
Name of Funeral Home 01 1 99
Address
6357 NYS Rte. 30, Indian Lake, NY 12842
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains s ri ed above as indicated.
Date Issued 1- 7- O f Registrar of Vital Statistics ,r\i _._u z.,
(signatur5
District Number S(p a. Place J,.... c e-�e5}ter- vv
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /$/ l to Place of Disposition &IL./ e-91,
(address)
(section) ` plot number) (grave number)
41.
Name of Sexton or Person in Charge of Pr raises ilni 1-10
F .
please print)
Signature Title d1'0141,4-
(over)
DOH-1555 (02/2004)