Devino, Adam itsvf
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Adam Paul Devino Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 15, 2014 28 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville Street Address
. Manner of Death Natural Cause'ti Accident Homicide Side 0 Undetermined Pending
Circumstances Investigation
Medical Certifier Name P - Title '`' i
Michael Sikirica,
Address
50 Broad Street Waterford, NY 12188
I.zr Death Certificate Filed District Number��� Register Number ��
City, Town or Village Granville (0
0 Burial Date Cemetery or Crematory
August 19, 2014 Pine View Crematory
❑Entombment Address
f ®Cremation Quaker Road Queensbury,NY 12804
Atf3 Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
r Transportation Shipment
by Common Destination
Carrier
u
1-1
Disinterment Date Cemetery Address
N.
Reinterment Date Cemetery Address
". Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
S Address
123 Main St., Argyle NY 12809
4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
li Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2 J ) I�' Registrar of Vital Statistics J
1', (signature)
District Number 5 gsop Place "gyptca-., 0--f <«r\D, I(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
:. Date of Disposition 08/19/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
, (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature �-- Title lliwl►
(over)
DOH-1555 (02/2004)