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Corliss, Delwyn It NEW YORK STATE DEPARTMENT OF HEALTH �_. ft R /f� Vital Records Section , Burial - Transit Permit Name First Middle Last Sex Delwyn Darwood Corliss Male Date of Death '1 Age If Veteran of U.S. Armed Forces, November.6, 2018 78 War or Dates Korea I Place of Death Hospital, Institution or iL City, Town or Village Moreau Street Address 243 Washburn Road W Manner of Death j Natural Cause n Accident n Homicide 1=1 Suicide ri Undetermined El Pending Circumstances Investigation W Medical Certifier Name Title John Mongan, Dr. Address 6 Medical Park Ballston Spa, NY 12020 Death Certificate Filed District(Umber Registerte Number City, Town or Village Moreau (4 _ ❑Burial Date Cemetery or Crematory November 13, 2018 Pine View Crematory 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date 1 Place Removed z C Removal and/or Held 7 and/or —Address Hold 0) Date Point of 0. n Transportatioh Shipment 0) by Common Destination 3 Carrier Date Cemetery Address ! I Disinterment I I Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home- SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address CC 111 Ct' Permission is he eby granted to dispose of the human reain ^ cribed a• • e a- ndicated. Date Issued I( � m U�La 1 Registrar of Vital Statistics likijo44 / w(signature) District Number Li D Place MOY. 0L4tf 14 [JOY • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: II•-- W Date of Disposition 11/13/2018 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) W co (section) (lot number) (grave number) Q Name Sexton or Person in Charge of Premises tir.3141— S tiAlit in of (plea print) W Signature ii IF— Title I17401v1i A_ (over) DOH-1555 (02/2004)