O'Rourke, Sean NEW YORK STATE DEPARTMENT OF HEALTH t 1/ 2
Vital Records Section Burial - i ransit Permit
Name First Middle Last Sex
Sean Christopher O'Rourke Male
li Date of Death Age If Veteran of U.S. Arm , Forces.
June 14, 2015 77 - War or Dates ) ej
Place of Death Hospital, Institution or
City, Town or Village 5PJt-.V Street Address Saratoga Hospital
Manner of Death� Natural Causj J Accident ❑ Homicide ri Suicide Undetermined r7 Pending
ilt 1---'Circumstances Investigation
Medical Certifier N m ?,,1,..,
.5 . S ,1c�A-(,SAQQ- S `v S Ml /?
Death Certificate Filed
DiStFict Ni. b Register Number
City, Town or Village 51 4- '-� I SCr)
❑Burial Date Cemetery or Crematory
June 16, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
0 Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Renterment
Permit Issued to Registration Number
-��X Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
s> 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 ranted to dispose of the human remains ' e°lbov icated.
Date Issued J Registrar of Vital Statistics 0—r*V^
(signature)
District Number -1$p1 Place d 50Q L 3 .3
. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/16/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number (grave number)
< Name of Sexton or Person in ChAarge of Premises �'+r,� ►+K#
lease print)
Title
i_.
Signature /i�Frioti4l(.
9
(over)
DOH-1555 (02/2004)