Killian, John NEW YORK STATE DEPARTMENT OF HEALTH it 16
Vital Records Section ' Burial - Transit Permit
Name First Middle Last Sex
John Patrick Killian Male
• Date of Death Age ' If Veteran of U.S. Armed Forces,
November 2, 2012 81 War or Dates
Place of Death Hospital, Institution or
' City, Town or Village Street Address Glens Falls Hospital
Manner of Death L Natural Cause n Accident 0 Homicide D Suicide in Undetermined ri Pending
Circumstances Investigation
• Medical Certifier Name Title
Dean Reali, Dr.
Address
3767 Main St. Warrensburg, NY 12885
i• Death Certificate Filed District Number Register Number
City, Town or Village �? j ��
0 Burial Date Cemetery or Crematory
November 5, 2012 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12504
R Date Place Removed
Removal and/or Held
4, and/or Address
Hold
Date Point of
`,[]Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
• Address
136 Main Street, South Glens Falls NY 12803
t 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 t t / Z,// Z Registrar of Vital Statistics CA. ,Q— (1 ). -•k-i-
(signature)
District Number 5601 Place 6 s is ( t S , /t/ 7 la(O
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11/05/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) . (lot number) (grave number)
Name of Sexton or Pers n in Charge o Premises /Ito t 04 it
(please print)
Signature L_ Title C114 r1-1 c0C
(over)
DOH-1555 (02/2004)