Tilford Jr, Lester It J Ito
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section t Burial - Transit Permit
Name First r , Middle Last ` Sex
`.-eb}e'f `Ill t 1501 Tilford \J r• Male
": Date of Death Age If Veteran of U.S. Armed Forces,
.a; October 11, 2011 75 War or Dates
' Place of Death Hospital, Institution or
' -z-. City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Mark Hoffman, Dr.
Address
n. 102 Park Street Glens Falls, NY 12801
Death Certificate Filed District i{t� RegiAhyrtber
City, Town or Village ( /
;440 Date Cemetery or Crematory
October 17, 2011 Pine View
0 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
Carrier
Disinterment Date Cemetery Address
Aif,. LiIfl
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
�,` Address
123 Main St., Argyle NY 12809
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 10 J)z j i) Registrar of Vital Statistics LA)cA,A,Y,_k kij.(sigro
District Number 5 60) Place l..5 re.,V\s , V 9
:' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
: Date of Disposition 10/17/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Per n in Charge o Premises ar) +,/3),(r- "�
(please print)
* ik_
„; Signature Title CR r
g �a
(over)
DOH-1555 (02/2004)