Paquette, Douglas NEW YORK STATE DEPARTMENT OF HEALTA • T
Vital Records Section Burial - Transit Permit3j.
Name First
Middle Last Sex
Douglas Edward Paquette Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 10, 2015 54 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Kingsbury Street Address 116 Dike Road
' Manner of Death ..� ❑ Undetermined ❑ Pending
: �� Natural Cause Accident ❑ Homicide El Suicide
Circumstances Investigation
Medical Certifier Name Title
Scott Miller,
Address
7
Death Certificate Filed District Number Register Number
R` 5'7 City, Town or Village Kingsbury a 7
Kti Date
❑Burial Cemetery or Crematory
June 12, 2015 Pine View Crematory
❑Entombment Address n
It-®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
` and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destinat :n
' Carrier
❑ Disinterment
Date Cemetery Address
ElReinterment Date Cemetery Address
Ocv
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
_. Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
Permission is hereby granted to dispose of the human remain escribed above as indicated.
:. Date Issued (Q-1 o/' Registrar of Vital Statistics ' c., �,�e_t.___
(signature)
District Numbers-76 a Place ut_1,..L_ W,`
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/12/2015 Place of Disposition Quaker Road Queensbury,NY 12804
a; (address)
(section) it
(tot numb (grave number)
Name of Sexton or Person in Charge of Premises G •,� �*
(please print)rrot4w
Signature Title itilot
(over)
DOH-1555 (02/2004)