Durkee Jr, Ralph if
NEW YORK STATE DEPARTMENT OF HEALTH e * 30
Vital Records Section Burial - Transit Permit
, Name First Middle Last Sex
Ralph Durkee Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
4 January 9, 2014 77 War or Dates
m Place of Death Hospital, Institution or
' City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Fri.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
• Medical Certifier Name Title
' ' Gamal Khalifa, Dr.
Address
100 Park Street Glens Falls 12801
Death Certificate Filed District Nu j Register Nw er
City, Town or Village Glens Falls /
❑Burial Date Cemetery or Crematory
January 13, 2014 Pine View Crematory
❑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
74 74 ❑ Disinterment
Date Cemetery Address
V❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
1144 123 Main St., Argyle NY 12809
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 desc d bo as) ted.
itg41 Date Issued Q//0 2O/y Registrar of Vital Statistics ,€'% /
(signature)
g District NumbeLZ/ Place 6k43ccr Jj , i' / Y/
'p
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/13/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /1 \
(lot number) - (grave number)
C,
th 7 Name of Sexton or Person in harge of P emises r3e r 04-
( ease print)
Signature Title CAI, i'
(over)
DOH-1555 (02/2004)