Boynton, Dan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dan Guilford Boynton Male
Date of Death Age If Veteran of U.S. Armed Forces,
0 9/1 7/2 01 6 70 War or Dates NA
16- Place of Death Hospital, Institution or
WOt, Town or Village Glens Falls Street Address The Pines at Glens Falls
0 Manner of Death❑x Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
O.
Medical Certifier Name Title
P Bernardo Villajuan MD
Address
161 Carey Rd. Bldg 2, Queensbury, NY 12804
Death Certificate Filed District Number_ , Regi$terk.rimer
Number
sty, Town or Village Glens Falls � � 4
❑Burial Date C�mete or Cremato I
09/22/2016 Pine View Crematory
❑Entombment Address
!ii,i®Cremation 21 Quaker Rd. Queensbury, NY 1 2804
Date Place Removed
Z n Removal and/or Held
.... and/or Address
I Hold
GI
C? Date Point of
5 El Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Fh 01 078
Address
136 Main St. So. Glens Falls, Ny 12803
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above .
Address
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!' Permission is hereby granted to dispose of the human r ..ains de cribed bove as iced" ated.
ED Date Issued 0 J/pjJB, Registrar of Vital Stag t s ate,, , 1 j
signs ure)
District Number f-too.i Place , r43L-e6 W
I certify that the remains of the decedent identified above wer- disposed of in accordance with his permit on:
ill Date of Disposition 9 f 23/4 Place of Disposition Pf71a U;,Q14) G-/Y-irt iJ c1
(addres
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in
CC (section) (lot number) (grave number)
Per on in C arge of Premises
Name of Sexton ag -)1"-L an CCLrYIr-G 4.1
.fir (please print)
41
Signature / Title C../12,y -a
t a
(over)
DOH-1555 (02/2004)