Wilkins, William If
NEW YORK STATE DEPARTMENT OF HEALTH IRS
Vital Records Section ..fir + Burial - Transit Permit
__ Name First Middle - Last Sex
William J. Wilkins Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 24, 2011 , 66 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death a Natural Cause 111 Accident ❑ Homicide ❑ Suicide ❑ Undetermined El 1---I Pending
CircumstancesInvestigation
Medical Certifier Name Title
John P. Stoutenburg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number / O 1 Register Number
City, Town or Village C� L G
❑Burial Date Cemetery or Crematory
N4 September 26, 2011 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal
and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
R' Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment
Date Cemetery Address
At
4F Permit Issued to Registration Number
,* Name of Funeral Home M. B. Kilmer Funeral Home 01079
`µ Address
82 Broadway, Fort Edward NY 12828
0.1 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 remains described above as indicated.
Date Issued Q /2G/f/ Registrar of Vital Statistics LA.) W—9-1P34
• (signature)
,= ,, District Number S 60( Place 6 1 S \\S f Al 9
al
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/26/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) t�c` (lot number) (grave number)
Name of Sexton or Pers in Charge o Premises (((( ,Ni-* Arfit
lease print)
' Signature y(1 -- Title C� 1�1Y}iU�
(over)
S55(02/2004)