Dillon, Catherine NEW YORK STATE DEPARTMENT OF HEALTH !- "" ' I
Vital Records Section Burial - Transit Permit
;� Name First Middle - Last Sex
E1 Catherine Lee Dillon Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 16, 2011 91 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc.
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri 1--I Pending
CircumstancesInvestigation
Medical Certifier Name Title
`' Rick D Teetz, Dr.
Address
131 Lawrence Street Saratoga Springs, NY 12866
Death Certificate Filed District Number � — ` Register umber
6 City, Town or Village 0/ 7,
❑Burial Date Cemetery or Crematory
August 18, 2011 Pine View
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
I I Transportation Shipment
by Common Destination
Carrier
ft°3 ❑ Disinterment Date Cemetery Address
illReinterment Date Cemetery Address
IV Permit Issued to Registration Number
V.
Name of Funeral Home M.B. Kilmer Funeral Home 01078
'' Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
k Permission is hereby ranted to dispose of the human remai rib d abo as 'ndicated.
Date Issued Registrar of Vital Statistics "��)w�
(signature)
District Number C` 70/ Place _ SARATOGA SPRINGS
'_< I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/18/2011 Place of Disposition Quaker Road Queensbury,NY 12804
r'
(address)
' (section) (lot number (grave number)
• Name of Sexton or Pers in Charge of remises ( ctjkr -A�� L (please print)
Signature (�' Title Ott; h Tye.
9 `RT
(over)
DOH-1555 (02/2004)