Dickson, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH c
Vital Records Section Burial - Transit( Permit
Name First Middle Last Sex
Elizabeth Joanna Dickson Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 1, 2017 91 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Washington Center
Manner of Death IL.]Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0. Circumstances Investigation
W Medical Certifier Name Title
Cl Edit Masaba, MD Dr.
Address
35 Gilbert Street Greenwich, NY 12834
Death Certificate Filed District Number Register Number
City, Town or Village Argyle /5a /
❑Burial Date Cemetery or Crematory
January 3, 2017 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
E Hold
01 Date Point of
a ❑Transportation Shipment
• by Common Destination
O Carrier
A Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
�t
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
7 Address
�� 136 Main Street, South Glens Falls NY 12803
Y Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued //3/ / Registrar of Vital Statistics ,, � ,. EL .A.A-
(signature)
District Number s 7s Place Ail'y )t Ili
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition 01/03/2017 Place of Disposition Quaker Road Queensbury,NY 12804
aL (address)
W
g (section) /' (lot number)` (grave number)
Name of Sexton or Person in Charge of P mises (ifs r Je-mi
tt
r(lelease print)
1 Si nature a Title I eltfirek
9
(over)
DOH-1555 (02/2004)