Moltrup, Ronald NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section c Burial - Transit Permit
Name First Middle Last Sex
Ronald Moltrup Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 21, 2016 71 War or Dates
Place of Death Hospital, Institution or t
City, T iw or Village 44 bror' Street Address 2-0 c 2
.Jcxivt S a-
Manner of Death Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name 1" ��
Dr. Eric Pillemer, �"
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed i District Number Register Number
ow ,�e.City, n r Village ' .�rOn '5.-�1 'Q 2
❑Burial Date Cemetery or Crematory
June 22, 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
I_❑Transportation Shipment
by Common Destination
a Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home-Axe 4e 010x/
Address adadal fatett /A/° (IV
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W.
Permission is hereby granted to dispose of the human rerniins des ribe� above as ' dicatg�.
Date Issued 6 --j , 16 Registrar of Vital Statistics /. '- ,.- (�h�-
(signature)
=T: District Number „5-70 Place He 41eeit)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z'
I Date of Disposition 06/22/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
0
I (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises /��j f Sim*
lease print)
r Signature -~ TitleM�p�C
(over)
DOH-1555 (02/2004)