Payne, Sidney NEW YORK STATE DEPARTMENT OF HEALTH 77 i
Vital Records Section . ,.,; Burial - TransitPermit
Name First Middle Last Sex
Sidney Lewis Payne Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 27, 2016 89 War or Dates
Place of Death Hospital, Institution or
I , City, Town or Village Argyle Street Address 124 Moon Road
Manner of Deathini Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Patricia Auer,
Address
316 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number is
City, Town or Village Argyle 1 j b
❑Burial Date Cemetery or Crematory
-,� March 29, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
_e n
Carrier
` ❑ Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
s - 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
vo Remains are Shipped, If Other than Above
. Address
" Permission is hereby granted to dispose of the human re ins described above as indicated.
`-C.Q.91
�' Registrar of Vital Statistics � � �LceW,,a�,
Date Issued �I�� � ((, _.
I (signature)
District Number 515 b Place A y5 i 1.< i IQ\j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t Date of Disposition 03/29/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
;.. (section) (lot number) (grave number)
4
Name of Sexton or Person in Charge of Premises fh( - 3k.
please print)
r Signature a Title 1ZE44114f,
(over)
DOH-1555 (02/2004)