Tillotson, Edward NEW YORK STATE DEPARTMENT OF HEALTH v iiiII �)OL
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward Hilton Tillotson Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 30, 2015 85 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
fManner of Death 0 Natural Cause ❑ Accident ❑ Homicide I I Suicide ❑Circumstances Undetermined ❑ Investigation Pending
Medical Certifier Name Title
Scott Biasetti, M.D. Dr.
Address
r ` 100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls .j 601 'Z-? 5
❑Burial Date Cemetery or Crematory
June 1, 2015 Pine View Crematory
❑Entombment. Address
*,„'®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
I. `❑ Removal and/or Held
and/or Address
Hold
v Date Point of
InTransportation 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- FE 01079
Address
82 Broadway, Fort Edward NY 12828
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.
J
- Date Issued 6 � i / l Registrar of Vital Statistics ( 3 O ne-e..
�
6 (signature)
District Number 56 0 1 Place ��S l
vc� , w
:5 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/01/2015 Place of Disposition Quaker Road Queensbury,NY 12804
i# (address)
(section) (lot numbL (grave number)
Name of Sexton or Perso in Char a of Premises ��•r
( lease print)
•
Signature Title
(over)
DOH-1555 (02/2004)