Myers, Donald Frederick A 51 ,
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donald Frederick Myers Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/07/2022 79 Years War or Dates 1963-69 •
Place of Death Hospital,Institution or
ZCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
p Manner of Death [ ]Natural Cause []Accident []Homicide []Suicide []Undetermined []Pending
W v / /Circumstances I 'Investigation
W Medical Certifier Name Title
CI Derek Smith MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 407
[]Burial Date Cemetery,Crematory or Facility Name
07/11/2022 Pine View Crematory
[]Entombment
Address
IIICremation Queensbury Town,New York
Donation
oZ❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
a Date Point of
Cl)[]Transportation
El by Common Shipment
Carrier Destination
ri Disinterment
Date Cemetery Address
Date Cemetery Address
❑Reinterment
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
M Address
M
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O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/11/2022 Registrar of Vital Statistics DitCon Moran(E(ectronica((y Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Date of Disposition ��ill Z2 Place of Disposition rt-.�
2 (address)
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Cl)
CC (section) A /lot
number) (grave number)
0 Name of Sexton or Person in Charge of Premises n��pL'.__
Z ./9 lease print) ,�i�,�',,
W Signature ZTitle rR '"•�[��—
DOH-1555(07/18)p 1 of 2
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Public Health Law Sec. 4145(2b)
1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#