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Dickerson Sr, Izel NEW YORK STATE DEPARTMENT OF HEALTH' , 1 'fig' Vital Records Section Burial - Transit Permit Name First Middle Last Sex Izel Dickerson Sr. Male Date of Death Age If Veteran of U.S. Armed Forces, January 23, 2017 61 War or Dates Place of Death Hospital, Institution or ill City, Town or Village Glens Falls Street Address Glens Falls Hospital CI Manner of Death .i Natural Cause ❑ Accident Homicide ❑ Suicide ❑ Undetermined ❑ Pending 0 Circumstances Investigation W Medical Certifier Name Title 0 Charles Yun, Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Numb Registerm N� ber City, Town or Village Glens Falls ,��jf l � 0 Burial Date Cemetery or Crematory January 25, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed zElRemoval and/or Held and/or Address E Hold QDate Point of 0. ❑Transportation Shipment CO by Common Destination p Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom t Remains are Shipped, If Other than Above Address iX tlt". Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued i. " Z$ 1( 7 Registrar of Vital Statistics W c. 3, L,L) (signature) District Number s L O I Place G (s)A,--5 , 1 \S Ni JJ i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition 01/25/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) COUi (section) (lot number) (grave number) Q Name of Sexton or Person in Charge of Premises t%���.S( 1 �^ ff Meese print) W Signature it Title R i*1 2.. (over) DOH-1555 (02/2004)