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Wade, Roy NEW YORK STATE DEPARTMENT OF HEALTH f ?7 Vital Records Section Burial - Transit ermit 27 Name First Middle Last Sex Roy Myron Wade Male - Date of Death Age If Veteran of U.S. Armed Forces, April 14, 2015 -Er5- 6 1 War or Dates Place of Death Hospital, Institution or -0 City, Town or Village Street Address 288 Dick Hill Road Manner of Death R71 Eki Natural Cause ❑ Accident 0 Homicide n Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Dr. Eric Pillemer, Address * 100 Park Street Glens Falls, NY 12801 fti Death Certificate Filed District Number Register Number I City, Town or Village `p,ip❑Burial Date Cemetery or Crematory April 15, 2015 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 � as❑ Removal Date Place Removed 1-1 and/or Held - and/or Address Date Point of -❑Transportation Shipment , by Common Destination Carrier I , Disinterment Date Cemetery Address ., Date CemeteryAddress ,N El Reinterment r 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 h reby granted to dispose of the human remain escribabo - MI! cated. p-T� 11(1 Date Issued �{ 15S Registrar of Vital Statistics . IkAi k -�' � �� r (signature) District Number 5`�5 Place4i-4 �f��,' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: r Date of Disposition 04/15/2015 Place of Disposition Quaker Road Queensbury,NY 12804 (address) ® (section) (lot nuber) (grave number) ,' Name of Sexton or Person in Charge of Premises aminot- . ‘"4l`- (please print) ar Signature (- ./.� Title `�z`�"`� (over) DOH-1555(02/2004)