Dixon, Beverly NEW YORK STATE DEPARTMENT OF Hh=ALT+4 ti► 4t 335
Vital Records Section Burial - Transit Permit
iii Name First Middle Last Sex
Beverly Paula Dixon Female
Date of Death Age If Veteran of U.S. Armed Forces,
7-2-2011 73 War or Dates No
} Place of Death 30 Hillcrest Ave Hospital, Institution or
City, Town or Village Queensbury, NY Street Address
Manner of Death Q Natural Cause 0 Accident ❑Homicide 0 Suicide riUndetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
0 Paul R. Philion MD
Address
3 Irongate Center Glens Falls, NEw York 12801
I Death Certificate Filed District Number Regis umber
City, Town or Village Tn. cif Queensbury 5( 7
Date Cemetery or Crematory
L. Burial 7-5-2011 Pine View Crematory
Address
ax Cremation 21 Quaker Road Queensbury, New York 1 2804
Date Place Removed
g0 Removal l and/or Held
and/or Address
5. Hold
0 Date Point of
%0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Datb Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registr Ua idtion Number
Name of Funeral Home M. B. Kilmer Funeral Home 0
Address
136 Main St. South Glens Falls, New York 12803
>;«: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
m
m
Permission is hereby granted to dispose of the human rem ins described abov s indicated.
iig
ill Date Issued 7-5-2011 Registrar of Vital Statistics JJ,L.
iiiii
«`> (signature)
<< District Number s(cs� Place Tn. of Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Thiel Place of Disposition Rn.stjvU 6P+110r4,,
(address)
CD
CC (section) 7/) (tot umber)C (grave number)
AName of Sexton or Perso in Charge of remises r% r- 1,1WA—
F (please print)
W Signature 1 Title COFmr`CO e—
(over)
DOH-1555 (9/98)