Dickinson, Anna NEW YORK STATE DEPARTMENT OF HEALTH Lill
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anna Belle Dickinson Female
Date of Death Age If Veteran of U.S.Armed Forces,
F October 28, 2006 84 War or Dates
Z Place of Death Hospital, Institution or
W City,Town, or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
G Medical Certifier Name Title
W Dr. Evanglos Pallis, M.D. Dr.
0 Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls .5 6 0 f 5 '3 9
❑Burial Date Cemetery or Crematory
October 31, 2006 Pine View Crematory
D Entombment Address
in ❑X Cremation Quaker Road Queensbury, NY 12804
I Date ' Place Removed
0 0 Removal and/or Held
and/or Address
Hold
0 Date Point of
0 E Transportation Shipment
0. by Common Destination
Carrier
Date Cemetery Address
OEl
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01141
Address
136 Main Street, South Glens Falls, New York 12803
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
it
W Address
0.
Permission is hereby granted to dispose of the human remains described�as in ' ate .
Date Issued 10/:. i 10 6 Registrar of Vital Statistics ��
(signature)
District Number Sj 6o 1 Place Glens Falls,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 10/31/2006 Place of Disposition Pine View Crematory
2 (address)
W
N
iY (section) / lot number) (grave number)
O Name of Sexton or Person in Charge of Premises (J lu- s �‘)en nr It
2 g /)/ (please print)
tit
Signature Title rey}or
(over)
DOH-1555 (02/2004)