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Cote, Ronald • NEW YORK STATE DEPARTMENT OF HEALTH,,- , r 4 L Vital Records Section Burial - Transit ermit Name First Middle Last Sex Ronald Phillip Cote Male Date of Death Age If Veteran of U.S. Armed Forces, December 13, 2016 79 War or Dates Place of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address 63 5th Street Manner of Death X❑Natural Cause I=1 Accident ❑ Homicide El Suicide El Undetermined El Pending Circumstances Investigation Medical Certifier Name Title Anthony Petracca, Dr. Address 3 lrongate Center Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5 601 6 I -6 El Burial Date Cemetery or Crematory December 19, 2016 Pine View Crematory 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address Hold Date Point of Transportation Shipment 0. by Common Destination 0 Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 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 0", Permission is hereby granted to dispose of the human remains describ zli3v7indi22_,Date Issued /,gyp 3%201 G Registrar of Vital Statistics (signature) District Number 5-60 , Place 6(svv`S-} I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ui Date of Disposition 12/19/2016 Place of Disposition Quaker Road Queensbury,NY 12804 II Aefa , (address) C (section) 1 j (loto number) (grave number) 0 Name of Sexton or P rs n in Charge of Premises �Ji"•(` �`'' �� E' - (please print) W' Signature Title �Lrn (over) DOH-1555 (02/2004) .