Severance, David NEW YORK STATE DEPARTMENT OF HEALTH
53l
Vital Records Section Burial - Transit Permit
w
Name First Middle Last Sex
David Lee Severance Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 27, 2016 68 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address 75 Main Street
Manner of DeathEli Natural Cause Accident ID Homicide El Suicide Undetermined 17 Pending
Circumstances Investigation
>I Medical Certifier Name Title
Douglas Dennett, M.D
Address
84 Broad Street Glens Falls, NY 12801
i Death Certificate Filed District Number Register Number
'..` City, Town or Village Argyle J /S 6
❑Burial Date Cemetery or Crematory
July 28, 2016 Pine View Crematory
;0 Entombment Address
''MCremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
❑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
i. 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 described above as indicated.
Date Issued I Z s / /b Registrar of Vital Statistics in, i..
( (signature)
District Number 5 3-6 Place l" 7`1 Lt )ill Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/28/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) A (lot number) (grave number)
_, Name of Sexton or Person in Charge of Premises r ..(Jt'�
/1e % (please print)
Signature (�,t �"a'" Title C P 1'4
(over)
DOH-1555 (02/2004)