Duell, Paul NEW YORK STATE DEPARTMENT OF HEALTH • '
S70
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Paul Raymond Duell Male
x Date of Death Age If Veteran of U.S. Armed Forces,
f-,-T., January 4, 2015 64 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ 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
44:- Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 b 0 i 6 0,5
❑Burial Date Cemetery or Crematory
January 5, 2015 Pine View Crematorye❑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
ElDisinterment Date Cemetery Address
W
.❑ Reinterment Date Cemetery Address
°4. Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
zos
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
Permission is hereby granted to dispose of the human remains described above as indicat .
a. �I
1 Registrar of Vital Statistics
Date Issued f� _� �/� ����/Y�'� ��
(signature)
District Number ,iz 60 ( Place 6 c QoS `\S i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
, Date of Disposition 01/05/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
° (section) (lot number)- (grave number)
Name of Sexton or Person incharge of Premises ar,, �""'
. 4 ( lease print)
: Signatures Title c;r N
(over)
DOH-1555 (02/2004)