Hearl, Joseph NEW YORK STATE DEPARTMENT OF HEALTH ` -' N. t / 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseph Peter Hearl Male
= Date of Death Age If Veteran of U.S. Armed Forces,
mv June 13, 2015 66 War or Dates
L Place of Death Hospital, Institution or
riF City, Town or Village Fort Edward Street Address 48 Burgoyne Ave
Manner of Death J Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
John P. Stoutenberg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed Dtrict N ber RegisNumber
City, Town or Village Fort Edward �-
0 Burial Date Cemete or Crematory
>= June 16, 2015 Pine View Crematory
Wi❑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
Carrier
IllDisinterment Date Cemetery Address
r r❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
a a 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 y gr ted to dispose of the human r- s described a ove as in '' ated.
Date Issued /S /� Registrar of Vital Statistic -e-,
(signature)
District Numbers-'755 Place Z1 A 9,..,i
I certify that the remains of the decedent identified a ve were disposed of in accordance with this permit on:
Date of Disposition 06/16/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
f (section) (lot number) (grave number)
v " Name of Sexton or Perso in C arge of Premises f+i S L"u'�—
(p/ ase print)
Signature '-" Title abFAllai
(over)
DOH-1555 (02/2004)