Hafner, Paul NEW YORK STATE DEPARTMENT OF HEALTH r # 1
Vital Records Section Burial - Transit iermit
Name First Middle Last Sex
Paul Elmer Hefner _ Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 3, 2018 50 War or Dates
• Place of Death Hospital, Institution or
w City, Town or Village Fort Edward Street Address 12 Thomas Ave
CI Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Ut
Circumstances Investigation
U' Medical Certifier Name Title
Robert Lemieux,
Address
219 Pope Hill Road Argyle, NY 12809
Death Certificate Filed District Number Register Numb r
City, Town or Village Fort Edward 5��� ,5
❑Burial Date Cemetery or Crematory
June 7, 2018 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
Hold
C. Date Point of
0. ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
. Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
XRemains are Shipped; If Other than Above
Address
Et
1lt Permission is hereby granted to dispose of the hum:j -r:ins.des ib ov as indicated.
Date Issued _�-J S Registrar of Vital Statistics �� Y '
�� (signature)
District Number r� 165 Place I Mart-► `. j '"_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w• Date of Disposition 06/07/2018 Place of Disposition Quaker Road Queensbury,NY 12804
111
(address)
CO
rt (section) , (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ff 4, itAAt
/j lease print)
t Signature h 4 Title 1P-( -'
(over)
DOH-1555 (02/2004)