Stevens, William E. NEW YORK STATE DEPARTMENT OF HEALTH �oD
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William E. Stevens Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 22, 2017 86 War or Dates
l' Place of Death Hospital, Institution or
�,,; City, Town or Village Argyle Street Address 1026 County Route 46
Manner of Death E.iNatural Cause 0 Accident 0 Homicide 0 Suicide ❑ Undetermined ❑ Pending
lit
Circumstances Investigation
I Medical Certifier Name Title
0 Charles Yun,
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Numb
City, Town or Village Argyle �� 55 3
❑Burial Date Cemetery or Crematory
November 27, 2017 Pine View Crematory
❑Entombment Address
Cremation Quaker Road Queensburr,NY 12804
Date Place Removed
Z'� Removal and/or Held
and/or Address
_E Hold
0 Date Point of
a.`❑Transportation Shipment
CO by Common Destination
0 Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Z. Address
Permission r' i i ated.is hereby granted to dispose of the human rem ns described above as c
Date Issued /f-a Aot7 Registrar of Vital Statistics ej-ttC
_ / c ^(signature)
District Number 5f7F5 Place f t.TiJ 7 66 /VZL G r((1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I• Date of Disposition 11/27/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
(X (section) /� (lot numbe) (grave number)
aName of Sexton or Person in Charge of P emises L r s +t
(pl ase print)
lid Signature Title z1 fr
(over)
DOH-1555 (02/2004)