Villmore,Terry L 40 # 3S5
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Nauru- First Middle List Sex
Teitk..Vilimore Male
Date of Death Age 11 Veteran of U.S.Armed Forces,
04/20/2022 68 Years War or Dates
H Place o1 Death Hospital,Institution or
Z City,Town or Village Kingsbury Town Street Address 122 Vaughn Road,Kingsbury Town,New York 12839
p Manner of Death El Natural Cause []Accident []Homicide []Suicide []Undeterrrrined []Pending
au I 'Circumstances 1 lnvesligation
U Title
ILI Medical Certifier Name a
0 John 1414cen Coroner
Address
40 Burquist Road,Fort Ann Town,New York 12827
Death Certificate Filed Town Of Kingsbury District Number Register Number
City,town or Village 5762 8
[ ]Burial Date Cemetery,Crematory or Facility Name
04/26/2022 Pine View Crematorium
0Ertontbmera Address
[]Cremation Queensbury Town,New York
Donation
n Date Place Reproved
O I I Removal
andjor andjor Held
i- Ifold Address
U)
0
O. Date Point of
U) transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
nDisinternrerd
Date Cemetery Address
inReinterment
Permit Issued to Registration Number
Narne of Funeral Horne Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
I... Remains are Shipped,11 Other than Above
2 Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/26/2022 Registrar of Vital Statistics C rtfiray:I4 ruff[](Elctrvn144 Sujnyd
(slgaalurel
District Number 5762 Place Town Of Kingsbury
I certify that the remains o1 the decedent identified above were disposed of in accordance with this permit um
Z Date of Disposition II/21IZZ Place of Disposition trail/..- i/jd"—
W (addrr s)!
W
CCCC (seklinni (lot ntrinket! e� (Sravenumbed
Name of Sexton or Person in Charge uses t 1`"
offj (ple scprnl,' p )j
tu Signature / Title ! �i
DOH-1555(07i18)plot 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on hruri-al permit
Official Funeral Directors Reg.or License#