Mainville, Emile NEW YORK STATE DEPARTMENT OF HEALTH t cV
Vital Records Section Burial - Transit I�Crmit
Name First Middle Last Sex
Emile A. Mainville Male
Date of Death Age If Veteran of U.S. Armed Forces,
:: November 8, 2011 86 War or Dates World War II
. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Stanton Nursing Center
ciManner of Death x Natural Cause Li Accident n Homicide Suicide Undetermined Pending
' _ Circumstances Investigation
w Medical Certifier Name Title
Suzanne Blood MD
Address
14 Manor Drive Queensbury,NY 12804
Death Certificate Filed District Numbe5657 Rggister Number
City, Town or Village Town of Queensbury a i
❑Burial Date Cemetery or Crematory
El Entombment November 9,2011 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road,Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
H Hold
N
0 Date Point of
O.
Transportation Shipment
5 by Common Destination
Carrier
n Disinterment Date Cemetery Address
1-1 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
iiii.M Remains are Shipped, If Other than Above
, Address
' Permission is hereby granted to dispose of the human re ains described above as indicated.
G . �S
Date Issued l � � � �� O Registrar of Vital Statistics �� 6lLc..,
(signature)
District Number 5657 Place Town of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
111 Date of Disposition jvov % Pi,
S I WO Place of Disposition .t Vea.J �rPr+rc ill f,,.r
(address)
W
N
rt (section) / (lot�ber (grave number)
p /Name of Sexton or Person in Charge of remises LI4 .r , 4j4-
Z (please print)
IliSignature Title CIL Ef641412-
(over)
DOH-1555(02/2004)