Fitzgerald, Boaz NEW YORK STATE DEPARTMENT OF HEALTH x
Vital Records Section Burial - Transit rermit
„, Name First Middle Last Sex
Boaz Fitzgerald Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 15, 2017 \ft.,,\A-rvi 1aci,1 War or Dates
Place of Death 1 Hospital, Institution or
F City, T=ewnnztWegge Street Address SOMA C1 i
Manner of Death❑Natural Cause 0 Accident 0 Homicide D Suicide Undetermined DTI Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Sikirica , Dr.
Address
50 Broad Street Ste 1 Waterford, NY 12188
Death Certificate Filed District Number ir- Register Number
el%Town or Village �A.{) Za p¢ ,\ (-,/5(`�( 9�/
rial Date Cemetery or Crematory //
l February 21, 2017 Pine View Crematory
I ❑Entombment Address
�� Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ti. Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is her by anted to dispose of the human remains d n e a ve as ' ted.
Date Issued z �—) ( ') Registrar of Vital Statistics
(signature)
District Number 5'01 Place Spp...(A.)�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/21/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) lot number) ;+ (grave number)
Name of Sexton or Person in Charge of Premises r� J1 v
/y� (pi ase print)
Signature t/` Title OCO vgbq
(over)
DOH-1555 (02/2004)