Paulson, Donald NEW YORK STATE DEPARTMENT OF HEALTH ` . r•Y V 10
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald Hugh Paulson Male
Date of Death Age If Veteran of U.S. Armed Forces, Q
tie July 1, 2013 88 War or Dates , t Li��
Place of Death Hospital, Institution or
City, Town or Village Street Address The Pines
Manner of Death El Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski, Dr.
- Address
14 Manor Drive Warrensburg, NY 12885
Death Certificate Filed District Numb i Regist utyber
City, Town or Village ll��
❑Burial Date Cemetery or Crematory
r. July 2, 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
rv, ❑ Disinterment Date Cemetery Address
• 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.
• Date Issued -2 I Z f( 3 Registrar of Vital Statistics l.A)C..,41� W
(sign ure)
District Number 5 6 0 / Place 6 ,,, s , \ 1 s t y
-�. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/02/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) ,(blot number) C (grave number)
Name of Sexton or Person in Charge of P emises [[ (+ �r —Iv.at
(plepse print)
• Signature Title GZC*t Thh(L
(over)
DOH-1555 (02/2004)