McCullum, Daniel ft
NEW YORK STATE DEPARTMENT OF HEALTH* . A NEW
Vital Records Section Burial - Transit Permit
Name Firsaniel Middle Thompson 1VIcCullum Sex Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/02/2012 77 years War or Dates
I- Place of Death Hospital, Institution or
ZQJ Xown or\Nl X Colonie Street Address 501 Old Niskayuna Road
Manner of Death❑,Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Illy Circumstances Investigation
Ca
la Medical Certifier Name Title
CI Steffini Cotsni DO
• Adc by Koute 146, Clifton Park, New York 12065
Death Certificate Filed District Number Register Number
C i )own or VX Colonie 153 151
❑Burial Date Cemetery or Crematory
08/06/2012 Pine View Crematory •
❑Entombment Address
[QCremation Queensbury, New York
Date Place Removed
t ri❑Removal and/or Held
..- and/or Address
h= Hold •
Cl)
O Date Point of
tLE Transportation Shipment
0 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 •
Address
82 Broadway, Fort Edward, New York 12828 ,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
lL
Permission is hereby granted to dispose of the human remains d scribed above as indicated.
Date Issued 08/03/2012 Registrar of Vital Statistics ' �o-'Z--v
(signature)
District Number 153 Place Colonie
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k �
t Date of Disposition $-7-1t Place of Disposition �' AVttw r_i(vrtot ,
a' ' (address)
ill
Ul
(section) A
(lot number) �- (grave number)
flName of Sexton or Person in Charge Premises " r -�eitmef
(please print)
Z#
lt! Signature Title Cite_P}R e.,
(over)
DOH-1555 (02/2004)