Tiu, William 709
NEW YORK STATE bErPgRTMENTSF HEALTH'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Go Tiu Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 20, 2015 6.3 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident ❑ Homicide ❑ Suicide ❑ Undetermined III Pending
Circumstances Investigation
W' Medical Certifier Name Title
William Cleaver, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 6 0 i to ( d
0 Burial Date Cemetery or Crematory
December 21, 2015 Pine View Crematory
❑Entombment Address
`_' ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
E Hold
N Date Point of
a ❑Transportation Shipment
CO by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 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
tt
Wet
Permission is hereby granted to dispose of the human remains described above as indicated.
`' Date Issued ;Z i 2., t 115 Registrar of Vital Statistics ,o ) ('A ALA... If
/� (signature) p
District Number 5 6c)I Place v �S Vim,, \\S ` p y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
P.h La s-zl u) C re..wieolg r
Date of Disposition 12/21/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
w
e (section) /(lot number) (grave number)
Name of Sexton o Perso in Charge of Premises - LJs c,� �`� .4-
(please print)
„i Signature Title e-rrnz,-4o
(over)
DOH-1555 (02/2004)