Boes, Keith 8
NEW YORK STATE DEPARTMENT OF HEALTH # �3
Vital Records Section Burial - Transit Permit
iii Name First Middle Last Sex
Keith G Boes Male
iE Date of Death Age If Veteran of U.S. Armed Forces,
07/19/2011 59 years War or Dates Yes
Place of Death Hospital, Institution or
5 City, TowJillORxX Glans Falls Street Address Glens Falls Hospital
0 Manner of Death❑1ptural Cause Q Accident 0 Homicide 0 Suicide ❑Undetermined Q Pending
Circumstances Investigation
ill Medical Certifier Name Title
3 Named A Sidderg M D
Address
Glens Falls Hospital 100 Park Street Glens Falls
nil Death Certificate Filed District Number Register Number
City, Towlotx) il7r$XXX Glens Falls 5601 325
❑Burial Date Cemetery or Crematory
❑Entombment 07/21/2011 Pine View Cemetery
Nii Address
Mi❑Cyemation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
C? Date Point of
IL
❑Transportation Shipment
L by Common Destination
Carrier
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Mi Permit Issued to Registration Number
iiIiii Name of Funeral Home Maynard D. Baker Funeral Home 01130
ig Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;; Address
it
f
!3 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/21/2011 Registrar of Vital Statistics
(signature
District Number 5601 Place Glens Falls
,"., I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition )itch 1 Place of Disposition PiNt U,r _ ant oe-ut
(address)
la
til
CC (section) ailAufit
,(lot number (grave number)
O.it Name of Sexton or P on in Charg f Premises r P0.ttf
2 I (please print)
Signature ^�.� Title 4141 ^�+�-
piiii C t
(over)
DOH-1555 (02/2004)