Dixon, Alden NEW YORK STATE DEPARTMENT OF HEALTH Nvt()
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
It Alden .kee-- Dixon Male
Date of Death Age If Veteran of U.S. Armed Forces,
IV September 2, 2011 75 War or Dates I q 5 S— 195c1
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 30 Hillcrest Ave
• Manner of Death1771
E.i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
of David Cunningham, Dr.
Address
vlt 3 Irongate Glens Falls, NY 12801
Death Certificate Filed D act Number Register Number
City, Town or Village
❑Burial Date Cemetery or Crematory
September 7, 2011 Pine View
❑
�,; Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
j Date Point of
tri Transportation Shipment
by Common Destination
-' Carrier
1111 Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
1 Address
gii 82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
3.- Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described ab r as indicated.
Date Issued I Ca I aO ►) Registrar of Vital Statistics C, �
_ (signature)
District Numbers(,"fl Place 16 cam- 0-c c ,,,
I certify that the remains of the decedent identified above were disposed of in acco nce ith this permit on:
Date of Disposition 09/07/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or P son in Char of Premises ft
r,5't. }.i- "'_t�
(pease print)
Signature Title 07Ee114102
(over)
DOH-1555 (02/2004)