Tillotson, Chester . -it
NEW YORK STATE DEPARTMENT OF HEALTH s g7r
Vital Records Section , Burial - Transit Permit
Name First Middle Last Sex
Chester Brooks Tillotson Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/02/2018 88 Years War or Dates 1951-1955
H Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death ri Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Ci Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 517
❑Burial Date Cemetery or Crematory
11/05/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Z ❑Removal and/or Held
H
and/or Address
Hold
CO
O Date Point of
13- ❑Transportation Shipment
• by Common Destination
Carrier
❑Disinterment Date —j Cemetery Address
❑Reinterment Date I Cemetery Address
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
t_- Remains are Shipped, If Other than Above
2K Address
fit
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/05/2018 Registrar of Vital Statistics Men ACurtis(ErectronicarrySigned)
(signature)
District Number 5601 Place Glens Falls, New York
} I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z (Kit,.
W' Date of Disposition A 16 its Place of Disposition 4J,..,, l AN t
W' (address)
N
Ce (section) (lot number) (grave number)
ct Name of Sexton or Person in Charge of Premises t k.,44p SL"i)
Z (please prirft)
W Signature _ Titled
(over)
DOH-1555 (02/2004)