Hilton, Jake 0•031" '
NEW YORK STATE DEPARTMENT OF HEALTH if /55 Ili
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jake Paul Hilton M
Date of Death 0 2/2 5/2 01 6 Age 3 9 If Mete an of U.S. Armed Forces,
*War or Dates
Place of Death Fort Edward Hospital, Institution or
W City, Town or Village Street Address 21 5 Broadway
IT Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑x Suicide ❑ Undetermined ❑ Pending
o Circumstances Investigation
WW Medical Certifier Name Title
Michael Sikirica MD
Address 50 Broad Street, Waterford,NY 12188
Death Certificate Filed Fort Edward District Numbed a Register Number
City, Town or Village J
0 Burial Date Cemetery or Crematory
❑Entombment Address
I Cremation
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
C ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
�'❑ Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB Kilmer Funeral Home 01 079
Address 82 Broadway, Fort Edward,NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tu.
'; Permission is he by g nted to dispose of the human s described above as ' icated.
Date Issue¢, Registrar of Vital Statisti �il,P_,06.....
.��� (signature)
District Numbe 5 / Place , k--) C %� " Zt i.J y /CV
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition 3/3)l{. Place of Disposition Jf .t Vlt4J �rw+igtau
" " (address)
L (section) Allot number) (grave number)
0 Name of Sexton or Person in Charge of remises i.4(i S¢o
(plea+�e print)
Iii Signature Title
1
(over)
DOH-1555 (02/2004)