Duswalt, Kevin Michael NEW YORK STATE DEPARTMENT OF HEALTH
Burial - Transit Permit
Bureau of Vitat Records
Name First Middle Last Sex
Kevin Michael Duswalt Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/12/2021 62 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Warrensburg Town Street Address 223 State Route 28 LOT 5,Warrensburg Town,New York 12885
p Manner of Death ❑X Natural Cause El AccidentHomicide Suicide ❑Undetermined El Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI Frances Bollinger MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Warrensburg 5660 22
IDBurial Date Cemetery,Crematory or Facility Name
09/14/2021 Pine View Crematory
❑ Entombment Address
ElCremation Queensbury Town,New York
❑Donation
O Removal Date Place Removed
and/or and/or Held
NE- Hold Address
0
EL Date Point of
❑
U) Transportation
by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
2 Address
CC
W
E' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/14/2021 Registrar of Vital Statistics Pa meth Llnyd Ekctronica*SOne4
(signature)
District Number 5660 Place Warrensburg, 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 9/(`�lt
10 11 Place of Disposition p; e V (�rerncdor y
(address)
W
Q (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises Sz.6'r~e,Y cS t)
(prase print)
W Signature /11/:/:,,eiTitle �/'e," t/cr
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
1
1 Human remains of ' - ` delivered on , 20 `}
1
1 - , ;
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors R'eg. or License#