Zollinger Jr., Ronald tal
NEW YORK STATE DEPARTMENT OF HEALTH #
Vital Records Section Burial - Transit Permit
Name First Middle La Sex
Ronald John ' ollinger Jr. M
Date of Death Age If Veteran of U.S. Armed Forces,
02/25/2017 55 War or Dates
Place of Death Albany Hospital, Institution or Albany Medical Center
City, Town or Village Street Address
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
usiCircumstances Investigation
Medical Certifier ° Name Gracie Linetters Title MD
Address
43 New Scotland Ave, Albany NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village Albany 10 1 `�--
nt ❑Burial Date 0 2/27/201 7 Cemetery or Crematory Rine View Crematory
❑Entombment
Address
[Cremation Queensbury,NY
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
['Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
El Disinterment
Date 4 Cemetery Address
❑ Reinterment
Permit Issued to Re Ii 0 7 Son Number
Name of Funeral Home MB Kilmer Funeral Home
Address
82 Broadway Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is b he y ranted to dispose of the human rem des ribed ] icatr ,
as Date lssued c��O� l l Registrar of Vital Statistics � U () n n ,
(signature)
District Number I C 1 Place V tt.l i ( t 4 �r�'1!��
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 7IZ8/17 Place of Disposition I" U'''r C lciler4�.
(address)
(section) /(lot number) S1 ,i-
rint)
(grave number)
Name of Sexton or Person in Charge of Premises✓� al (p asep
Signature it �]�t Title CREillill*-
(over)
DOH-1555 (02/2004)