Dixon, Jean NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
,i° Name First Middle Last Sex
Jean Estella Dixon
Female
'N Date of Death Age If Veteran of U.S. Armed Forces,
06/25/2018 75 Years War or Dates
Place of Death Hospital, Institution or
* City, Town or Village Glens Fallstti Street Address Glens Falls Hospital
Manner of Death N Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
Dean Reali DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 315
` ❑Burial Date Cemetery or Crematory
06/26/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
1 El Removal and/or Held
and/or Address
Hold
Date Point of
go Transportation Shipment
by Common Destination
-17 Carrier
u Disinterment
Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
,,,, Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
e Remains are Shipped, If Other than Above
2 Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/26/2018 Registrar of Vital Statistics TonertA Curtis(E(ectronicaftySigned)
(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:
Date of Disposition 4/Zt lit Place of Disposition P,. 4-1 o.. ..
(address)
(section) (lot nuqtpec) (grave number)
Name of Sexton or Person in Charge of Premisesif4',,t>k
(please prin
Signature �✓' Title MOM.
(over)
DOH-1555 (02/2004)