Sayer, Franz NEW YORK STATE DEPARTMENT OF HEALTH tr CO3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Franz Sayer Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 3, 2011 94 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El 1---I Pending
111
0.i.i CircumstancesInvestigation
Medical Certifier Name Title
Bernardo R Villajuan, Dr.
Address
48 East Street Fort Edward, NY 12828
Death Certificate Filed Drict�stN�um?r R�gjst�Number
City, Town or Village �� o��
0 Burial Date Cemetery or Crematory
December 7, 2011 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
in Transportation Shipment
by Common Destination
0 Carrier
[:I Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
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 move as indicated.
Date Issued tp-t c- I 11 Registrar of Vital Statistics Cat R A
---_—, (signature)
District Number ,,D- Place ) 0 ty,.i-- oc 0 i_,�es2,.
I certify that the remains of the decedent identified above were disposed of in accor c with this permit on:
Date of Disposition 12/07/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numbery... ``�' (grave number)
Name of Sexton or Person in Charge of remises d��s+ 2 t)rlt'1
(please print)
/AL
Si nature Title ���AT
111 Ut,
(over)
DOH-1555 (0 /2004)