North, Wayne Richard -#ggo
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Wayne Richard North Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/22/2021 79 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Hartford Town Street Address 7021 State Route 40, Hartford Town, New York 12809
p Manner of Death Natural Cause ❑Accident ❑ Homicide ❑Suicide ❑Undetermined ❑Pending
tL Circumstances Investigation
W Medical Certifier Name Title
CI Donald Merrihew MD
Address
319 Bay Road,Queensbury Town,New York 12804
Death Certificate Filed District Number I Register Number
City,Town or Village Hartford 5759 16
❑Burial Date Cemetery,Crematory or Facility Name
10/23/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Z• Removal Date Place Removed
and/or and/or Held
Hold Address
0
O. Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
Address
CC
uJ
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/22/2021 Registrar of Vital Statistics Denise(Petteys(ECectronicalTy Signed)
(signature)
District Number 5759 Place Hartford, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition /of 23 h'ZI Place of Disposition ito-ILI
�i� dfs�
2 (address)
uJ
CC (section) (lot number) (grave number)
• Name of Sexton or Person in Char Premises f
Tease print)
z (094 4Pft
W Signature 6 Title
DOH-1555(07/18)p 1 of 2
I Public Health Law Sec. 4145(2b)
I
1 Receipt
I
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#