Dixon, Matthew NEW YORK STATE DEPARTMENT OF HEALTH /%,;4.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex 373
Matthew M. Dixon Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. August 18, 2006 35 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Albany Street Address Albany Medical Center
G Manner of Death 0 Natural Cause n Accident ❑ Homicide n Suicide Ei Undetermined Pending
til Circumstances Investigation
0 Medical Certifier Name Title
W Herman Thomas coroner
Q Address
112 State Street, Albany, NY 12207
Death Certificate Filed District Number `�' Register Number
City,Town or Village Albany
(1 Burial Date Cemetery or Crematory
August 24, 2006 Pine View Cemetery
❑Entombment Address
Q Cremation Quaker Road Queensbury, NY 12804
Z Date Place Removed
0 El Removal and/or Held
so and/or Address
l' Hold
0 Date Point of
0 0 Transportation Shipment
A by Common Destination
i Carrier
Date Cemetery Address
d0 Disinterment
n 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
ix Remains are Shipped, If Other than Above
W Address
a
Permission is hereby granted// to dispose of the human remains described above as indicated.
Date Issued cl`& i` 0 Registrar of Vital Statistics a C , klitelVitO
(signature) '
District Number /0 ( Place Albany,New York
t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 08/22/2006 Place of Disposition Pine View Cemetery
2 (address)
W
to
It (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises ( e•S Svi n t'tr
2 (please print)
W
Signature i� -t Title �rc",c4 oc
(over)
DOH-1555 (02/2004)