Purinton, Lyle NEW YORK STATE DEPARTMENT OF HEALTH ` 4 )o Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lyle Arthur Purinton Male
Date of Death Age If Veteran of U.S. Armed Forces,
_;,w September 24, 2015 66 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Northumberland Street Address 318 Purinton Road
Manner of Death X❑ Natural Cause ❑ Accident n Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
ftt Medical Certifier Name Title
Michael Sikirica , Dr.
j Address
50 Broad Street Ste 1 Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village Northumberland t'-1Cjl 1`J
Date Cemeteryor Crematory
❑Burial September 28, 2015 ine View Crmatory
4 ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
3,`❑ Removal and/or Held
-a.. and/or Address
Hold
At
.� Date Point of
nTransportation Shipment
- byCommon
Destination
Carrier
. ❑ Disinterment Date Cemetery Address
= �,[1 Renterment 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
Address
`7, Permission is hereby granted to dispose of the human re ains described above as indicated.
ti Date Issued Miaril i'= Registrar of Vital Statistics r ��
(signatu
District Number 1-iStA Place-Lon OP 1 v nY-Y'1`.-)r(YIC,J2._v-1 ._n A _
: ,_,
, ,,li I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/28/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton r Pers n in Charge of Premises - 1A-ha_A mac-1, e
(please print)
4
Signature Title C re n7a-1-67 ASS%3`1�,.,
(over)
DOH-1555 (02/2004)