McIntosh, Sr. Ervin it Lo34
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Pe mit
Name First Middle Last Sex
Ervin 41 - s McIntosh Sr. Male
0,1 Date of Death Age If Veteran of U.S. Armed Forces,
{
December 1, 2012 62 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Warrensburg Street Address Old State Route 9
,> Manner of Death Natural Cause Accident 0 Homicide 0 Suicide Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
William A. Tedesco, M.D. Dr.
Address
3 Irongate Center Glens Falls, NY 12801
'° Death Certificate Filed District Number ��T Register N er
City, Town or Village ,�
l - 0 Burial Date Cemetery or Crematory
December 4, 2012 Pine View
0 Entombment Address
®Cremation uacer Road Queensbury,NY 12804
Date Place Removed
" 0 Removal
and/or Held Pine View
and/or Address
Hold Quaker Road Queensbury,NY 12804
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
.. 0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Ife: Address
123 Main St., Argyle NY 12809
:` Name of Funeral Firm Making Disposition or to Whom
4 Remains are Shipped, If Other than Above
Address
Permission is he eby granted to dispose of the human r describ d abov as i dicated.
Date Issued f Z 4 /Z Registrar of Vital Statistics
(signature)
District Number 5(4 0 Place U)?,-17044 I,tt) 11,1, e.JVO,,,_/(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/04/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
"'
,, (section) (/ot tuber) (grave number)
75604
Name of Sexton or ers in ge of Premises aF1 d
(please print)
i
Signature Title '
(over)
DOH-1555(02/2004)