Daly, Lawrence 11607
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lawrence Daly Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/21/2021 89 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Guilderland Town Street Address 11 Birch Drive,Guilderland Town,New York 12203
W Manner of DeathPending
� Natural Cause �Accident �Homicide El �Undetermined El
W Circumstances Investigation
LU Medical Certifier Name Title
Miranda Dunham Nurse Practitioner,Family Health
Address
433 Rivers St,Troy,New York 12180
Death Certificate Filed District Number Register Number
City,Town or Village Guilderland 0155 123
Burial Date Cemetery,Crematory or Facility Name
07/26/2021 Pine View Crematory
riEntombment Address
0 Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
H Hold Address
0
Date Point of
Cl) Li Transportation Shipment
by 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
Remains are Shipped,If Other than Above
5 Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/23/2021 Registrar of Vital Statistics Lynne Buchanan(ECectronicalTy Signed)
(signature)
District Number 0155 Place Guilderland, 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 7- -J-1 Place of Disposition Pi iv- ✓j cyV (,rtfr
ILI 2 ad ress)
W
CC (section) (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises S trim' /e'S
0 (please print)
W , 1./r1t $ ,✓ Title �.rt./►+` ee
Signature
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)^° ` 1,4 9 7 6
Receipt
Human remains of delivered on , 20
`-
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#