Myott, Richard NEW YORK STATE DEPARTMENT OF HEALTH r # 3►
I -
Vital Records Section - Burial - Transit Permit
• Name First Middle : Last Sex
Richard Leonard Myott Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 17, 2012 77 War or Dates \q b(1 _lcl S S
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Pleasant Valley
Manner of Death Fri Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Edit Masaba, MD Dr.
Address
200 Main Street Greenwich, NY 12834
Death Certificate Filed District Number 1/457 Register Nu
City, Town or Village Argyle
El Burial Date Cemetery or Crematory I
June 18, 2012 Pine View Crematory
0 Entombment Address
r -
®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
❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
:: Address
136 Main Street, South Glens Falls NY 12803
T. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
s Address
Permission is ere y granted to dispose of the huma ains//►�descri d above indicated.
Registrar of Vital Statistic�Q.(_
Date Issued 9�
(signature)
District Number ��� Place Te(D
„....
?0,3 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on.
Date of Disposition 06/18/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) ill
4 (lot number) (grave number)
Name of Sexton or Pe on in Charge f Premises c:A Ut"a4/ 0
please print)
SignatureL Title 61041N ,
(over)
DOH-1555 (02/2004)