Dilley, Ian 01/27/2017 17.39:28 3153696'342 PAGE 01/0.1
NEW YORK STATE DEPARTMENT OF- HEALTH
Vitai Records Secti _on Burial - Transit Permit
:...: Name Firtrn tyliddlemichael Leilliay l, SexMaie
Date of Death -TAge I If Veteran of U.S. Armid Farces,
!.H. 01/24/2017 ' 40 years War or Dates n/a
Place of54-eith Hospital, Institution or
I Town or Webb _l_Street Address Snowmobile Trail#5
Mariner of Death 0 Natural Cause {_.-- Ac6dent L Jr"Homic—ide—Li"Su-i—cide rljUrtger Tri, eia--- r--rW,Fccirn-g-- ,P Circumstances `-'-`investigation,
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4 Medical Certifier Name Title Michael Sikirica Medical Examiner
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c... Aottass
Pu broad St; Waterford, N Y121138
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Iii,atli certificate Filed , . i pistrict Number , _ TiFiegister Number
019(town crXXAYA Webb ' 2167 - . - 2'ri
L_I Burial 1 Date Cemetery or Crematory
01/27/2017 Pine View Crematory
I:Entombment'
::•! .i.,.„ Address
Cremation Queenstury, NY
Place Removed
ri m Reoval '
ql,I-1 : anc/or Held
and/or LAddiess
Hold ,
Date
-77—Paint of
Di0 Transportation -
iz _LShipment — —: by Common Destination
•
Carrier
-- 0 nterment
'.1-Deite ).
Cemetery Address.
t--
,- Dare
. - u Reintermert '
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-ermit Issued to ----7 listratien Number
Name of Funeral Home Mb Kilmer F drieral Home , 01079
Address
82 Broadway, For Edward, NY 12828
Name of Funeral Firm Making Disposition or to Whim
C.::. Remains are Shipped, If Other than Above 1
'r•-:. Address
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,.... Permission is hereby granted to dispose of the hurnah emalns descriab 4 as indicated,
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01/27/2017 ,-,
Date Issued Registra•of Vital Statistics / i L.L,t,
_ ____
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N- 7—. (1Wmen':tr4'' 7'e-----
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:•.H'' District Number 2167 Place Webb
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I certify that the remains Y the decedent identified above were dispoaed of in accordance with this permit on:
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Date of Dispositior '00 IQ Place of Dsposition
into,, 61r442
(ad6rees)
' (vestiorl.; 47 r"(ct nniovr) rave:lumber;
:.., Name of Sexton or Person in Charge Of PronTses
_
ii Signature A l'_ ): _ Title eese prire`,1 __,
- -
(over)
DOH-1558 (02/2004)