Germain, Terry L. 4 3(r)
NEW YORK STATE DEPARTMENT OF HEALTH .
Vital Records Section - Burial - Transit Permit
Name First Middle Last Sex
TERRY L. GERMAIN Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/09/2021 53 War or,Dates
M. Place of Death Hospital, Institution or
W City, Town or Village Town of Waterford Street Address 132 Fonda Road
isU Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Lul Medibal Certifier Name Title
C.! David Kandath MD
Address
6 Care Lane, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Town of Waterford
Z.DIE3urial Date Cemetery or Crematory
[,DEntombment 04/12/2021 Pineview Crematory
Address
®Cremation Queensbury,NY
Date Place Removed
Z Removal and/or Held
0 and/or Address
H Hold •
U)
O Date Point of
%❑Transportation Shipment
Q by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
i Name of Funeral Home Densmore Funeral Home , Inc. 00448
Address •
7 Sherman Ave , Corinth, NY 12822
Ai Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
lit
Permission is hereby granted to dispose of the human r m n escriberi above as ' c t
Date Issued 04/12/2021 Registrar of Vital Statistics t/, f tka � u, T I ,(4/Vd
(signature)
District Number �5u g Place Town of Waterford , New York
''' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 IL Date of Disposition L1 1131 Z1 Place of Disposition `� 1;:;_____
2 (address)
0
f (section) lot number) (grave number)
aName of Sexton or Person in Charge of Premises / +rtt l- ,wAAA•if
(please int)
•
141 Signature „2 Title iliZCAYrk
(over)
DOH-1555 (02/2004)
at
. •
0 Public Health Law Sec. 4145(2b)
14 7
Receipt
•
Human remains of delivered on , 20
Pine View Cemetery Represent/fig the funeral home named on burial permit
Official Funeral Directors Reg.or License#