Wilson, Billie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Billie Wall Wilson Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/07/2017 86 years War or Dates
Place of Death Hospital, Institution or
City, TOCOC XtK ( Glens Falls Street Address The Pines At Glens Falls
tiia Manner of Death pg Natural Cause Accident 0 Homicide �Suicide Undetermined Pending
f Circumstances Investigation
tti Medical Certifier Name Title
Gwendolyn Momi-Dickinson Physician Assistant
Address
170 Warren Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, Tam VA( ( Glens Falls 5601 147
['Burial Date Cemetery or Crematory
03/08/2017 Pine View Crematorium
['Entombment Address
Q'Cremation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or Address
i= Hold
U)
C Date Point of
EL i—i
0 Li Transportation Shipment
E by Common Destination
Carrier
ii. Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
>. Name of Funeral Home M. B. Kilmer Funeral Home 01078
Address
136 Main Street South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
a Address
Er
f:
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/07/2017 Registrar of Vital Statistics UsCA.A.16-r\2- (A),./.:^Ce*
(sign
District Number 5601 Place Glens Falls d.
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit A � ,
Date of Disposition 3/QJ/7 Place of Disposition � 2 t,/;�,�f.,}C,1'-0.r�/'
/ / (address)ill
y
U)
CC (section) 1 (lot number) (grave number)
a
Name of Sexton or P rs n in Charge of Premises tit f i�-;� C.Dwra2G.-c<4 e'
2 (please print)
Signature Title 6-f2n�e40,0'"
(over)
DOH-1555 (02/2004)