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Dixon, Helen NEW YORK STATE DEPARTMENT OF HEALTH I r �' I Vital Records Section Burial - Transit Permit Name First Middle Last Sex Helen Marie Dixon Female Date of Death Age If Veteran of U.S. Armed Forces, February 13, 2017 73 War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address 8 Breton Way 0Manner> of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide III Undetermined ❑ Pending 0` Circumstances Investigation 111 U Medical Certifier Name Title Robert Lemieux, Address 219 Pope Hill Road Argyle, NY 12809 Death Certificate Filed District Number,...- Register Nmber t City, Town or Village Fort Edward ►�� ❑Burial Date Cemetery or Crematory February 14, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or,i Address Hold Date Point of ❑Transportation Shipment �; by Common Destination a Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above X: Address iii 11* Permission is here granted to dispose of the human e ins de crib dab ve i icated. Date Issue Li 01 Registrar of Vital Statistics V , (signature) te-- District Number '1v)� Place��u .. �W 06 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: lid Date of Disposition 02/ /2017 Place of Disposition Quaker Road Queensbury,NY 12804 rifle v', t?,;,J(,az,0/4,4 7- x (address) lii (section) ,,,�'- (lot number) (grave number) a Name of Sexton or.Perso ;ifi Charge of Premises L4 I r.tM(..-'1�o'16 U it.. t- (please print) z.__________. Signature , ,,i=- i Title C.-at 11- �' r' t� I (over) DOH-1555 (02/2004)