Loading...
Dow, Justin Allen 30 NEW YORKSTATE DEPARTMENT OF HEALTH `` Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Justin Allen Dow Male Date of Death Age If Veteran of U.S.Armed Forces, 01/05/2021 30 Years War or Dates F— Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 250 Old West Road, Moreau Town, New York 12831 LtJ p Manner of Death ❑ ❑ n Natural Cause Accident Homicide 1=1 Suicide Undetermined ©Pending W Circumstances Investigation LU Medical Certifier Name Title CI David DeCelle Coroner Address 40 McMaster Street,Ballston Spa,New York 12020 Death Certificate Filed District Number Register Number City,Town or Village Moreau 4562 2 Burial Date Cemetery,Crematory or Facility Name 01/09/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ElDonation Z Removal Date Place Removed and/or and/or Held H Hold Address W 0 00- Date Point of (/) Li Transportation Shipment p by Common Carrier Destination 0 Disinterment Date Cemetery Address Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W 0_ Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/08/2021 Registrar of Vital Statistics Leeann Mc cabe(Electronically Signed) (signature) District Number 4562 Place Moreau, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition /--ab / Place of Disposition ea,. wtti e t411.1 /a dress/ W N (section) (lot number) (grave number) CC 0 Name of Sexton or Person in Charge f Premises/ I. ici y 110,01 r' id)vb ei (please print) W Signature �� Title "9 DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) 014396 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#