Killian, Joseph NEW YORK STATE DEPARTMENT OF HEALTH 499
Vital Records Section _ Burial - Transit Permit
Name First Middle Last Sex
Joseph Killian Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. November 9, 2006 80 War or Dates
2 Place of Death Hospital, Institution or
W City,Town, or Village Fort Edward Street Address Fort Hudson Nursing Home
Cl Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Amy Hogan-Moulton M.D. Dr.
Q Address
2 Broad Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 55 J-Z)
❑Burial Date Cemetery or Crematory
November 14, 2006 Pine View Crematory
❑ Entombment Address
❑X Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 El Removal and/or Held
and/or Address
i' Hold
0 Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
0 Date Cemetery Address
oDisinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01142
Address
82 Broadway, Fort Edward, New York 12828
~ Name of Funeral Firm Making Disposition or to Whom
x• Remains are Shipped, If Other than Above
IL▪ Address
Permission is here y g nted to dispose of the human remain scribed a e as-indicated.
Date Issued �/ �� 4Registrar of Vital Statistic ..'�')C—
i nature)
District Number Place Fort Edward,New York
t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 11/14/2006 Place of Disposition Pine View Crematory
2 (address)
W
(1
Zt (section) lot number) (grave number)
Name of Sexton or Person in Charge of Premises C f'‘ S �i°,in err
W / (please print)
Signature C 1 Title Crem a i'o r'
(over)
DOH-1555 (02/2004)