White, Wayne NEW YORK STATE DEPARTMENT OF HEALTHQ`/r
Vital Records Section — , Burial - Transit Permit
Name First Middle Last Sex
g Wayne B. White Male
Date of Death Age If Veteran of U.S. Armed Forces,
3 �_ March 19, 2015 77 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
T- Manner of Death El Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
a. Circumstances Investigation
Medical Certifier Name Title
Sean Bain, M.D. Dr.
Address
z. 100 Park Street Glens Falls, NY 12801
_` Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 i 5 j
❑Burial Date Cemetery or Crematory
. March 23, 2015 Pine View Crematory
U Entombment Address
e ®Cremation Quaker Road Queensbury,NY 12804
V.4 Date Place Removed
❑ Removal and/or Held
• and/or Address
• Hold
Date Point of
'❑Transportation Shipment
by Common Destination
Carrier
n ❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
f; 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
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 / 23 //5- Registrar of Vital Statistics W LA),,,v-cenCt
(signature)
District Number 5 6 d ) Place 6 (c2itis 50, `\5 ,IJ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
Y
• Date of Disposition 03/11t/2015 Place of Disposition Quaker Road Queensbury,NY 12804
s, (address)
(section) umber) (grave number)
i 3..6 /� l
Name of Sexton o e on • arge of Premises °'� .�
a e. (pleaseprint)
Signature i� Title ' Q ,c1•
(over)
DOH-1555 (02/2004)