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Bregg, Paul NEW YORK STATE DEPARTMENT OF HEALTH - 77 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Paul J. Bregg Male Date of Death Age If Veteran of U.S. Armed Forces, October 25, 2016 89 -. War or Dates Place of Death Hospital, Institution or w City, Town or Village Glens Falls Street Address Glens Falls Hospital 0. Manner of Death Q Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation 4. Medical Certifier Name Title �/I Kasandra Frasier, 1"I Address Death Certificate Filed District Number ( Register Number City, Town or Village Glens Falls 500 D .❑Burial Date Cemetery or Crematory October 26, 2016 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 7 ❑ Removal and/or Held and/or Address H Hold Date Point of ti ❑Transportation Shipment by Common Destination Ei Carrier _ Date Cemetery Address ❑ Disinterment ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above E Address Cr Permission is hereby granted to dispose of the human remains described above,as indicated. Date Issued to i a6 l 2.0)6 Registrar of Vital Statistics c._A4 )— . —AN (signatu e) District Number 5 O) Place 6 t_c_tv‘S c l gu J I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 10/26/2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) w I (section) ���� (lot number) (grave number) Name of Sexton or Person in Charge of Premises dr,stott .�Co4tH ( ease print) W Signature Title niktAr , (over) DOH-1555 (02/2004)