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Bloomfield, Paul NEW YORK STATE DEPARTMENT OF HEALTH k SO3 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Paul Bloomfield Male ;: Date of Death Age If Veteran of U.S. Armed Forces, s. November 4, 2016 73 War or Dates Place of Death Hospital, Institution or . City, Town or Village Argyle Street'Address 59 Main Street Manner of Death 1771.i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending Circumstances Investigation Medical Certifier Name Title William Rohan, Address 325 Main Street Hudson Falls, NY 12839 zit Death Certificate Filed District Number SAS 0 Register Number City, Town or Village Argyle47 ❑Burial Date Cemetery or Crematory November 7, 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 ❑Transportation Shipment by Common Destination 4. CI Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077 Address 123 Main St., Argyle NY 12809 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 ///1//{, Registrar of Vital Statistics \lvi, ►,1+ (signature) District Number 5156 Place tj t my Imo' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 11/07/2016 Place of Disposition Quaker Road Queensbury,NY 12804 ,` (address) (section) /' (lot numb (grave number) lName of Sexton or Person in Charge of Premises L , ^^«` please print) Signature �C --In' Title rn m filVa (over) DOH-1555 (02/2004)