Killon, Kerry - 67
NEW YORK STATE DEPAaTMpski OF HEALTH Vital Records Section � 'Burial - Transit Permit
Name First Middle 4.,.. Last Sex
Kerry M. Killon Male
;-` Date of Death Age If Veteran of U.S. Armed Forces,
January 14,2017 73 War or Dates
Place of Death Hospital, Institution or
t City, Town or Village Minerva Street Address 41 Town Shed Road
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
tii Medical Certifier Name Title
Cil Jennifer Donovan K
Address
126 Ski Bowl Road, Johnsburg,NY 12843
Death Certificate Filed District Number Register Number
' City, Town or Village Minerva 1557
❑Burial Date Cemetery or Crematory
January 17,2017 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
ca
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
y;: Permit Issued to Registration Number
. Name of Funeral Home Alexander-Baker Funeral Home 00037
.1 Address
:': 3809 Main Street,Warrensburg,NY 12885
' z Name of Funeral Firm Making Disposition or to Whom
►' Remains are Shipped, If Other than Above
Address
'• Permission is hereby granted to dispose of the human r 'ns crib d above as indicated.
Date Issued 3CI t3 ,11 Registrar of Vital Statistics c n �� )
' :a r``i (signs )
.„,
;, District Number 1557 Place Minerva c_.-2 Qf
- .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition I hp In Place of Disposition , ias,,, feat,,,,,
Ill
(address)
U)
CL (section) (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises iirYtvir l: S.fAtff
Z (p ase print)
W Signature a Title (iii0fA .
(over)
DOH-1555 (02/2004)