Barlow, Stanley le
NEW YORK STATE DEPARTMENT OF HEALTH Burialt�
�t
Vital Records Section - Transit Permit
Name First Middle Last Sex
_., Stanley Joseph Barlow Male
:, Date of Death Age If Veteran of U.S. Armed Forces,
November 23, 2012 53 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 63 Rainbow Trail
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
T
Aqeel A. Gillani, M.D. Dr.
" Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Rp9is.ter Number
City, Town or Village Queensbury ��c---'1 a
❑Burial Date Cemetery or Crematory
November 27, 2012 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
v ❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
1 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 ranted to dispose of the human r mains described above as indicated.
Date Issued.1,1 z'61a01�Registrar of Vital Statistics C? __,Q, Cs\PM rl t_..___,
- --, (signature)
';',-Al
District Number', Place v li.rti d L �`
I certify that the remains of the decedent identified above were disposed of in accordance wit th s permit on:
• Date of Disposition 11/27/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) �/ (lot number) (grave number)
. Name of Sexton Person i harge of Premises �'� // 4��A d
G /t'sue tint) S
Signatur , '�'"� Title
(over)
DOH-1555 (02/2004)