Dillon, John NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Thomas Dillon Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/29/2017 96 Years War or Dates 1942-1945
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause Accident El Homicide D Suicide Undetermined 17 Pending
Circumstances Investigation
Medical Certifier Name Title
David Cunningham MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 555
❑Burial Date Cemetery or Crematory
10/30/2017 Pine View Crematory
['Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Date Cemetery Addre:
❑Disinterment -
Reinterment Date Cemetery Ad,'
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
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 10/30/2017 Registrar of Vital Statistics qtg6ertACurtis EfectronicalTySigned.
(signature)
District Number 5601 Place Glens Falls, New York
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition If /I in Place of Disposition nt1J.. Ct4rna}o t fw.
(address)
(section) 'f (lot number) ( (grave number)
Name of Sexton or Person in Charge of Premises `At 0.
lecr
(p/ ase print)
Signature �� Title r�E1�1
(over)
DOH-1555 (02/2004)