Amell, Darrell it, 5
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Darrell Edward AmPll Male
, : Date of Death Age If Veteran of U.S. Armed Forces,
March22, 2013 48 War or Dates NO
Place oo Death n. of Moreau Hospital, IAddress
or 249 Old Saratoga Rd Apt. D
,`; City, Town or Village' Street Address g P
Manner of DeathEic Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
£ - Medical Certifier Name Title
;; John Sawyer MD
V Address
161 Carey Rd. Queensbury, NY 12804
Death Certificate Filed Tn. of Moreau District Number,5�? Register umber
City, Town or Village ��
DateCemeteryor Crematory
El Burialarch 25, 2013
❑Entombment Pine View Crematory
Address
❑Cremation 21 Quaker Road Queensbury, NY
,.., Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
z,'❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
IIIReinterment Date Cemetery Address
Permit Issued to Registration Number
f Name of Funeral Home M. B. Kilmer Funeral Home 01 078
-j- Address
136 Main St. South Glens Falls, NY 12801
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
F Address
Permission is hereby granted to dispose of the human rema' described above as indica d.
'4 Date Issued 3-2 5-1 2 Registrar of Vital Statistics M/U /0/, b.
(signature)
Tn. of Moreau, NY
District Number /--J�(0 Place
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
' Date of Disposition 3-1$-1:3 Place of Disposition ee tivJ c�^2 D yv..e1
(address)
(section) (lot number) (grave number)
a 9 � 3 � 1
•: .: Name of Sexton or Per on in Charge Premises � d �-i
please print)
Signature (43— Title Cibaterb11?�
(over)
DOH-1555 (02/2004)