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Farrand, Dale Cletus NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dale Cletus Farrand Male Date of Death Age If Veteran of U.S.Armed Forces, 12/09/2023 78 Years War or Dates 1965-65 H Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address 78 McCrea Street, Fort Edward Town, New York 12828 • Manner of Death El Natural Cause Accident EHomicide ESuicide Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title W William Parker MD Address 9 Carey Road,Queensbury Town, New York 12804 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 105 Burial Date Cemetery,Crematory or Facility Name 12/13/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation 0• Removal Date Place Removed and/or and/or Held H Hold Address 0 d Date Point of U) Transportation by Common Shipment Carrier Destination o Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls, New York 12803 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 5 Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/13/2023 Registrar of Vital Statistics Aimee£ Mahoney(ECectronicaCCySigned) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition It 1 1 t3 Place of Disposition ( NC .=..i (061"147M g•-. 2 (address) W CC CC (section) (lqi number) S/p4v (grave number) Name of Sexton or Person in Charge of Premises Z ( ease print) - W Signature C Title c ��TOC DOH-1555(07/18)p 1 of 2 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#