McEnerney, Roy ft
NEW YORK STATE DEPARTMENT OF HEALTH 717
Vital Records Section r Burial - Transit Permit
Name First Middle Last Sex
Roy McEnerney Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 16, 2013 70 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 1518 Saratoga Road
Manner of Death Natural Cause ❑ Accident n Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
2. Michael Sikirica,
al Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village Moreau
0 Burial Date Cemetery or Crematory
December 19, 2013 Pine View Crematory
❑Entombment Address
:,®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
k III Removal and/or Held
and/or Address
Hold
° Date Point of
Transportation Shipment
by Common Destination
Carrier
�.F ❑ Disinterment
Date Cemetery Address
❑ Reinterment
Date Cemetery Address
s
-ili Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
,_' 136 Main Street, South Glens Falls NY 12803
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 rem s described ab ve s indicated.
/i��Date Issued i a:�. Registrar of Vital Statistics / st-t.-lc.44_..e., t om-,
(signature)
District Number /(S(,, . Place /4711`77 ` -L,e_e.cc._
4.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
'. Date of Disposition 12/19/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) - (grave number)
Name of Sexton or Person in Charge f
Otis r Ou►PlR-
(please p ht)
, Signature Title C241110A,
(over)
DOH-1555 (02/2004)