Russell Sr., John t
NEW YORK STATE DEPARTMENT OF HEALTH 52,
Vital Records Section Burial - Tran%itPermit
eil Name First Middle Last Sex
John Martin Russell Sr. Male
''> Date of Death Age If Veteran of U.S. Armed Forces,
06/10/2017 86 years War or Dates
• Place of Death Hospital, Institution or
City, TcXXXOt'%iX ( Glens Falls Street Address Glens Falls Hospital
f Manner of Death Natural Cause O Accident Homicide Suicide �Undetermined �Pending
1 Circumstances Investigation
Medical Certifier Name Title
44. Jean Van Arken
Address
100 Park St Glens Alls, Ny 12801
Death Certificate Filed District Number Register Number
City, Tdaiftar igurgtx Glens Falls 5601 321
—
OBurial Date Cemetery or Cremate
06/12/2017 Pineview Cemei
`::OEntombment Address
[.Cremation Queensbury, N Y
Date Place Removed
O Removal and/or Held
and/or
it Hold
0
Hold
Date Point of
• O Transportation Shipment
2 by Common Destination
ui Carrier
O Disinterment Date Cemetery Address
:::':,,O Reinterment Date Cemetery Address
ft 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
Remains are Shipped, If Other than Above
• Address
M
Ili
,. Permission is hereby granted to dispose of the human remains described above as indicated.
>: Date Issued 06/12/2017 Registrar of Vital Statistics LAx,.�t, �,/\)
(si nature)
District Number 5601 Place Glens Fallsi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
Ili Date of Disposition &11,3117Place of Disposition - gI.J (rirrNOitar---
(address
U
1Z (section) /!/(lot number) (grave number)
cf Name of Sexton or Person in Charge of remises 6�kir� �"`"
(pl se print)
• Signature �"l Title 1 (L
(ovee).--------
DOH-1555 (02/2004)