Fowler, Daryl Howland _ # L3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Daryl Howland Fowler Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/08/2021 79 Years War or Dates 1966-1970
H Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
W Manner of Death
NINatural Cause E Accident 1=1 Homicide ElSuicide ❑Undetermined El Pendign
W Circumstances Investigation
W Medical Certifier Name Title
CI Rick Teetz MD
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 240
ElBurial Date Cemetery,Crematory or Facility Name
04/10/2021 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
F Hold Address
N
0
O. Date Point of
0 ❑Transportation Shipment
Esby Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
jr... Remains are Shipped,If Other than Above
2 Address
CC
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/09/2021 Registrar of Vital Statistics John aulcFranck(EhctronicallySigned)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: (1/
1- �Z Date of Disposition y'CZ Tl Place of Disposition "1 �' , (((�__
2 (address)
ILI
(section) (lot ro er) (grave number)
a
Q Name of Sexton or Person in Charge of Prem. please p ti�d1J '44�"f
!L4 Title (Ri [f rig
Signature
DOH-1555(07/18)p 1 of 2
f '
Public Health Law Sec. 4145(2b) 4
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#