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Dickens, Helen NEW YORK STATE DEPARTMENT OF HEALTH w Z Vital Records Section Burial - Transit Permit Name First Middle Last Sex Helen Irene Dickens Female .- Date of Death Age If Veteran of U.S. Armed Forces, January 4, 2017 78 War or Dates - Place of Death Hospital, Institution or City, Town or Village Kingsbury Street Address 28 Fairview Lane Manner of Death m uu Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Danushan Sooriabalan, Address Death Certificate Filed District Number Register Number City, Town or Village Kingsbury S 7(p D. 0 ❑Burial Date Cemetery or Crematory January 6, 2017 Pine View Crematory z-❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment 0 by Common Destination — CI Carrier • ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 • Address F` 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom 1Remains are Shipped, If Other than Above Address >- Permission is hereby granted to dispose of the human remains cribed above as indicated. ▪ Date Issued �0.ri.. S -3017 Registrar of Vital Statistics c'Z` a f i)Q-0--0---° t (signature) District Number 57b a Place `mo6—c------ \d;Y"9S I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ry' Date of Disposition 01/06/2017 Place of Disposition Quaker Road Queensbury,NY 12804 .f (address) ein (section) /' (lot number) (grave number) 45, Name of Sexton or Person in Charge o Premises L�roh/4`' /� lease pnn Signature �` Title 1nYtWL (over) DOH-1555 (02/2004)