Rourke, Daniel NEW YORK STATE DEPARTMENT OF HEALTH l ‘111 5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Daniel Rourke Male
Date of Death Age If Veteran of U.S. Armed Forces,
43 August 27, 2014 61 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address
Manner of Death 0 Natural Cause 0 Accident Ei Homicide El Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Dr. Eric Pillemer,
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number .
City, Town or Village D Go t boo
?0 Burial Date Cemetery or Crematory
August 28, 2014 Pine View Crematory
�� ❑Entombment
Address
14,®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
Al-,; Date Cemetery Address
w,o L j Disinterment
Reintermentft
Date Cemetery Address
Permit Issued to Registration Number
N• ame of Funeral Home M.B. Kilmer Funeral Home 01078
A• ddress
ft 136 Main Street, South Glens Falls NY 12803
4441. N• ame of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
' Address
i
Permission is he eby rante to dispose of the human re ains des ibed abov as i:ndica ed.
Date Issued G S egistrar of Vital Statistics l���.-, G
zillgnat re)
District Number a ( Place �—` S `�` 1
;
1 I certify that the remains of the decedent identified above were disposed of in accordance with t s permit on:
Date of Disposition 08/28/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) ,(lot numAer) (grave number)
- Name of Sexton or Person in Charge of Premises
n1 Jo matt
k" ,y (please print)
Signature ✓,(i"-- Title etai"?l1d01
(over)
DOH-1555 (02/2004)