Dekalb, Donald Wayne NEW YORK STATE DEPARTMENT OF HEALTH Z
Bureau of Vital Records IsiGHN 4
Burial - Transit Permi
Name First Middle Last Sex
Donald Wayne DeKalb Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/24/2022 79 Years War or Dates
F.. Place of Death Hospital,Institution or
WCity,Town or Village Granville Town Street Address 208 Beecher Road,Granville Town,New York 12832
Q Manner of Death []Natural Cause [] Homicide Suicide Accident []Undetermined ❑Pending
W II (Circumstances Investigation
0 Medical Certifier Name Title
John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Granville District Number Register Number
City,Town or Village 5756 32
Burial Date Cemetery,Crematory or Facility Name
05/31/2022 Pine View Crematory
[]Entombment Address
MCremation Queensbury Town,New York
Donation
D0Removal Date Place Removed
p and/or and/or Held
N Hold Address
0
O. Date Point of
U)❑Transportation
CI Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
OReinterment 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
F— Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/27/2022 Registrar of Vital Statistics Jenny Linda M 9Nartelte(ECectronica1TySigned)
(signature)
District Number 5756 Place Town Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l—
W Date of Disposition 6�t 1zz Place of Disposition roc s) '` I —
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2 /addres
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0 (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge Premises rote y�,t,��,(t-
Z L.%1 /ple�alke print/
Ili Signature Title
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DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of � �1.' 1,� -' delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
i .f
Official Funeral Directors Reg.or License# �r�