Boel, David NEW YORK STATE DEPARTMENT OF HEALTH *; ` 3 3
Vital Records Section y Burial - Transit Permit
Name First Middle Last Sex
David Boel Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 22, 2015 57 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death a Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Miles,
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 6 0 I ) 5'
❑Burial Date Cemetery or Crematory
March 30, 2015 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
Date Point of
t ❑Transportation Shipment
by Common Destination
flia Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
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
11. Permission is hereby granted to dispose of the human remains described above as in4icated.
Date Issued 312L-/ //3 Registrar of Vital Statistics t,�c��� iz W
(signature)
District Number 560 / Place 6 cQinS \\S 0 -('
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/30/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
PIE (section) A (lot number) (grave number)
Name of Sexton or Person i Charge of Premises "�_ St Avail
1
Please print)
Signature Title taktvrallort
(over)
DOH-1555 (02/2004)