Cavanagh, Patrick NEW YORK STATE DEPARTMENT OF HEALTH t # i 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patrick John Cavanagh Male
' Date of Death Age If Veteran of U.S. Armed Forces,
March 12, 2016 73 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Sponzo, Dr.
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register m�yer
City, Town or Village Glens Falls ��
❑Burial Date Cemetery or Crematory
March 15, 2016 Pine View Crematory
^,. ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
,i 0 Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
-71
illReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
:f Address
82 Broadway, Fort Edward NY 12828
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 above as indicated.
Date Issued 3 j 15 J Zo ► Registrar of Vital Statistics t/ ) Q oQ W.r�
(signature)
District Number 5 bO 1 Place �) LQv..s --0,\\S rdi V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/15/2016 Place of Disposition Quaker Road Queensbury,NY 12804
,: (address)
(section) /,, (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 1p11r01A --)eMr4t
J t (please print)
Signature .��( °' Title 1a 1 it_
(over)
DOH-1555 (02/2004)