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Green, Donald NEW YORK STATE DEPARTMENT OF HEALTH It Z(01 Vital Records Section 4 � Burial - Transit Permit Name First Middle Last Sex Donald L. Green Male Date of Death Age If Veteran of U.S. Armed Forces, May 20, 2012 91 War or Dates Place of Death Hospital, Institution or City, Town or Village Argyle Street Address Pleasant Valley Manner of Death m in j Natural Cause 0 Accident El Homicide l i Suicide El Undetermined n Pending Circumstances Investigation Medical Certifier Name Title Edit Masaba, MD Dr. Address 200 Main Street Greenwich, NY 12834 A " Death Certificate Filed District Number 1 Register N mber City, Town or Village Argyle �75� cD s ❑Burial Date Cemetery or Crematory '- May 23, 2012 Pine View Crematory . ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held and/or Address ,E= Hold Date Point of ❑Transportation Shipment by Common Destination = Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number ..' Name of Funeral Home M.B. Kilmer Funeral Home 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom -y" Remains are Shipped, If Other than Above `' Address Permission is h reby ranted to dispose of the human remainsin described Date Issued D 0(.1). Registrar of Vital Statistics .5 `„ (signature) District Number5 Place cia171(yLe..._,,_ fl I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t Date of Disposition 05/23/2012 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) A 1(lot number) (grave number) z Name of Sexton or Per on in Charg of Premises ( lease print) Z` Signature ' — Title cats 1OQ, (over) DOH-1555 (02/2004)