Jenkini, Richard MET
NEW YORK STATE DEPART Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Richard Jenkins Male
Date of Death Age If Veteran of U.S.Armed Forces,
F May 11, 2006 65 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 ❑Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Ageel A. Gillani, M.D. Dr.
Q Address
102 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number j Register Number
..—
City,Town or Village Glens Falls :� U lJ
0 Burial Date Cemetery or Crematory
May 13, 2006 Pine View Cemetery
❑Entombment Address
q ❑Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
4 ❑Removal and/or Held
and/or Address
r Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
i Carrier
Date Cemetery Address
Q ❑ 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
2 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
W Address
Permission is herebygranted to dispose of the human remains des ib d o as ' ted.
Date Issued . I 1 Z/0-6 Registrar of Vital Statistics I/
(signature)
District Number 3—b 0 L Place Glens Falls,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 05/13/2006 Place of Disposition Pine View Cemetery
2 (address)
W
41
1 (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises �.r, a �t� It c
Z ��A (please print)
W /
Signature (, f6t,. Title Cry •`kwf
(over)
DOH-1555 (02/2004)