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Palmer, Timothy 211 NEW YORK STATE DEPARTMENT OF HEALTH` Vital Records Section a Burial - Transit Per it ie Name First Middle Last Sex Timothy Joseph Palmer M Date of Death 0 3/0 9/2 01 8 Age 6 4 If Veteran of U.S. Armed Forces, War or Dates 1 9 71 -1 9 7 4 Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address 40 Fourth St. ill• Manner of Death© Natural Cause El Accident 0 Homicide El Suicide 0 Undetermined 0 Pending Circumstances Investigation Ili Medical Certifier Name Title Dr. Anthony Petracca MD Address Irongate Venter, Glens Falls,NY 12801 Death Certificate Filed District Number Register Number ig . Q City, Town or Village Glens Falls 1 ❑Burial Date 0 3/1 2/2 01 8 Cemetery or Crematory »»> Pine View Crematory Entombment AddressMi RI Cremation 21 Quaker Rd, Oueensbury,NY 12804 Date Place Removed ❑Removal and/or Held and/or E; Address i Hold O Date Point of 07:i El Transportation Shipment C by Common Destination Carrier Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address iiiig • iin Permit Issued to Registration Number iN Name of Funeral Home MB Kilmer Funeral Home 01 079 '' Address 82 Broadway, Fort Edward,NY 12828 iR Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above • Address Cr. t P" Permission is hereby granted to dispose of the human remains described above as indicated. ig Date Issued Registrar of Vital Statistics (signature 11111111111 District Numbers 6 o f Place 6 �'v5 \k \ s J I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k ILI Date of Disposition �J 11 kkk Place of Disposition ?N?N.C., /;/� 4_ (address) UI fin i (section) f (Ict number) (grave number) • Name of Sexton or Person in Char a of Premises l��T- 5.--"1' *I► //�,, lease print) • Signature G�' Title (fir, O.A. (over) DOH-1555 (02/2004)