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Boucher, Richard NEW YORK STATE DEPARTMENT OF HEALTH' % /' -)L I Vital Records Section Burial - Transit Permit ,` Name First Middle Last Sex Richard M. Boucher Male Date of Death Age If Veteran of U.S. Armed Forces, October 19, 2016 58 War or Dates wPlace of Death Hospital, Institution or \ City, Town or Village e W j ()In Street Address ((Q 016 �-� h�G\ Manner of Death ❑Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending ILLCircumstances Investigation Medical Certifier Name Title Daniel J. Kuhn, Address 40 McMaster Street Ballston Spa, NY 12020 Death Certificate Filed '' ',`` District Number� Registeirsber City, Town or Village 9a W1 It l'1 H . ❑Burial Date Cemetery or Crematory October 24, 2016 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 2❑ Removal and/or Held and/or Address Hold tit Date Point of ❑Transportation Shipment by Common Destination 14 Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 :. 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 her by g I ,nted to dispose of the human rema' s described abov of Vital Statistics v as indicated. Date issued / ta (A � Ct Registrar �"l � , 0 (signature) District Number /! 51.0�} Place / (51Un D a.)11 )ri . 4 ,_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ;, Date of Disposition 10/24/2016 Place of Disposition Quaker Road Queensbury,NY 12804 X (address) Ut Ot (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises t A milk,r S 4l'If g + (please print) Signature Title EMATdC- (over) DOH-1555 (02/2004)