Mylott, David Temple 1
NEW YORK STATE DEPARTMENT OF HEALTH '
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last
Sex
David Temple Myott Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/03/2023 75 Years War or Dates 1966-1970
1._ Place of Death Hospital,Institution or
Z City,Town or Village Hartford Town Street Address 32 Brayton Road,Hartford Town,New York 12827
W
0 Manner of Death ENatural CauseAccident Ei Homicide Suicide []Undetermined ❑Pending
W I
V Circumstances Investigation
QW Medical Certifier Name Title
Robert Southerland MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Hartford District Number Register Number
City,Town or Village 5759 1
[ ]Burial Date Cemetery,Crematory or Facility Name
01/04/2023 Pine View Crematory
['Entombment Address
gCremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
F, and/or and/or Held
N Hold Address
0
d. Date Point of
U) Transportation
CI Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment 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
IH 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 01/04/2023 Registrar of Vital Statistics Denise Petteyr(' ctronically,Sugned)
(signature)
District Number 5759 Place Town Of Hartford
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ii-
W Date of Disposition /--,5--ZOZ3 Place of Disposition T4,J r`9 ��,�i„c> L'r �
W (address)
U)
CC (section) (lot wither) (grave number)
0 Name of Sexton or Person in Charge of ?/1 y'f1.2.J?, iviesZ - (please print)WSi nature � /g Tr'Tiat/emises
Title OQo�Gy--M r
DOH-1555(07/18)pi of 2 V
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#