Churchill, George NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George William Churchill Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 4, 2013 89 War or Dates World War II
zPlace of Death Hospital, Institution or
W City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
W Manner of Death mLIJNatural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0
Daniel C. Larson, M.D. Dr.
Address
Broad Street Glen Falls, NY 12801
Death Certificate Filed District Number Regi3 r Number
City, Town or Village Fort Edward
®Burial Date Cemetery or Crematory
May 4, 2013 St. Alphonsus Cemetery
❑Entombment Address
❑Cremation Queensbury,NY 12804
Removal Date Place Removed
z ❑• and/or and/or Held
Hold Address
Date Point of
a ❑Transportation Shipment
CD by Common Destination
d Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
W
0 Permission is he by ranted to dispose of the human r 'rts described abo as indicated.
Date Issued Registrar of Vital Statistic
/�_ (signatu
District Number Place / ) i ( g,14.) ._/
•
I-- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ii,i• Date of Disposition 05/04/2013 Place of Disposition Queensbury,NY 12804
(address)
W r
CE (sec l (lot number) (grave number)
p• Name of Sexton Person in Charge of Premises C.u ` L .'C7 �g
(please print)
Signature Title Cl
(over)
DOH-1555 (02/2004)