Porteus, Patrick NEW YORK STATE DEPARTMENT OF HEALTh k A �S b 6
Vital Records Section G Burial - Transit Permit
^-, Name First Middle Last Sex
a
Nt Patrick Austin Porteus Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 27, 2011 41 War or Dates
Place •• -ath ems_ Hospital, Institution or
. City, own qr Village eenseveort Street Address 1541 West River Road
Mann- • Death X❑ Natural Cause ❑ Accident El Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Amy Hogan-Moulton, M.D. Dr.
Address
2 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 11 O f Qf L 1-1-..5-7p . ,.3
❑Burial Date Cemetery or Crematory
Nye November 28, 2011 Pine View
'; ❑Entombment Address
1®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ 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 01079
a'- Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
='- Address
d
Permission is hereby granted to dispose of the human remains described above as indicated.
g Lew' i d-�L. -I
Date Issued �� a 8 ) � I Registrar of Vital Statistics
6 I H LLq�Sor�(5-hr c��-Fh ( t"
5 O rs s --� I Z$03
u District Number `i E.-Rot.), Place + 0 W n 0-�' NI. 0 (Law N Li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
._ Date of Disposition 11/28/2011 Place of Disposition Quaker Road Queensbury,NY 12804
4' (address)
(section) (lot numberr (grave number)
Name of Sexton or Perso in Charge of emises actsky41 f Mrlt(please print)�l
a Signature 7 Title C MOB
(over)
DOH-1555 (02/2004)