Boucher, Ronald NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit5S)
Vital Records Section
iimoNsminommilinummk' :, Name First Middy = = Last Sex
Ronald Mitchell Boucher Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/27/2015 76 War or Dates 1958-1964
E= Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address Albany Medical Center
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ci Manner of Death Natural Undetermined Pending
'' Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑
Circumstances Investigation
W Medical Certifier Name Title
fa Pouya Entezami MD
Address
43 New Scotland Ave. Albany, NY 12208
/0 Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1603
Date Cemetery or Crematory
❑ Burial 07/28/2015 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
F- Hold
U)
0 Date Point of
a, Transportation Shipment
u) ❑ By Common Destination
p Carrier
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01087
Address
136 Main t. South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
F` Remains are Shipped, If Other than Above
2' Address
LiU'
d Permission is hereby granted to dispose of the human remain ribed above as indicated.
Date 07/28/2015 Registrar of Vital Statist'
Issued signature) /
District Number 101 Place City of Albany, NY J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z', Date of Disposition )'3o -(J Place of Disposition CP:/iQ vu'elV C1efrwatev-4,411
LU (address)
W''
(seon _ �(lot number) (grave number)
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' _Name of Sexton or Person in Charge of Premises T`�
(please print)
Signature Title e re the/71017 106S4 -
(over)
DOH-1555 (02/2004)