Keech, Randorum NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
t
Name First Middle Last Sex
Randorum Lyle Keech Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 26, 2017 68 War or Dates
tPlace of Death Hospital, Institution or
II City, Town or Village Street Address 15 Bluebird Road
fill' Manner of Death mIj Natural Cause 1=1 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Michael Adams, Dr.
Address
10154 Saratoga Raod Fort Edward, NY 12828
Death Certificate Filed District1 n?ber Register ber
City, Town or Village (p �j
❑Burial Date Cemetery or Crematory
April 28, 2017 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
H Hold
Vl Date Point of
a ❑Transportation Shipment
4) by Common Destination
G Carrier
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
L Remains are Shipped, If Other than Above
2` Address
Permission is hereby granted to dispose of the human remain describ a".ve as indicated.
Date Issued07/c. Y/y/7 Registrar of Vital /d/611(
�/ gnature)
District Number l(�2 Place 35/ 6,,(iicas /(1� ��% �®0,,� ` . / & ?
� •
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/28/2017 Place of Disposition Quaker Road Queensbury,NY 12804
W (address)
U)
Q (section) /(lot number) (grave number)
p; Name of Sexton or Person in Charge of remises /k.S ,— 3i' Il}
z (pl ase print)
W Signature AZ C�+�s'1+'�1'*1...
g � Title
(over)
DOH-1555 (02/2004)