Squires, Paul 9 NEW YORK STATE DEPARTMENT OF HEALTH + ti 1 L
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Paul Erwin Squires Male
l Date of Death Age If Veteran of U.S. Armed Forces,
October 23, 2013 75 War or Dates
' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident El Homicide ❑ Suicide ❑ Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
William Papura, Dr.
Address
1134 Rt 29 Greenwich, NY 12834
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5-6 O) 4-1 '-/ i
Cdy
0 Burial Date Cemetery or Crematory
October 25, 2013 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
Date Cemetery Address
❑ Disinterment
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
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 indicated.
AI
Date Issued GO /-2-,7 if � t`�
Registrar of Vital Statistics .3C0 �,� � L��
. � . k-i`-Cs-A
(signature)
District Number ) ( Place 6(Q\r-c V-J\ \\ ; Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/25/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) / (lot number) (grave number)
Name of Sexton or Person ' Charge of P mises v'�f Jrnj
(p1 ase print)
Signature
Title C2+EMAT0e
(over)
DOH-1555 (02/2004)