Vilmar, David -77
NEW YORK STATE DEPARTMENT OF HEALTH ..0 ) # g
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
David R. Vilmar Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 6, 2015 52 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause El Accident El Homicide El Suicide El Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Charles Yun,
Address
,` 102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 610( 5 Ql 1-i
❑Burial Date Cemetery or Crematory
December 11, 2015 Pine View Crematory
❑Entombment Address
: .n®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
A.❑Transportation Shipment
a' by Common Destination
a Carrier
- II Disinterment Date Cemetery Address
r ❑ Reinterment Date Cemetery Address
- 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
ti Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued )2/9 its Registrar of Vital Statistics LiOcum-y-0-- ULL),.."--eCis
(signature)
District Number 560 1 Place 6 Svo, . )s, 0.1 U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Y'11e i.)el.., 4"crr►ular;401
s Date of Disposition 12/11/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
' , (section) /' (lot number) (grave number)
is Name of Sexto or Person in Charge of Premises 3 -1<-.'. C�e,,-..,4e.... a
(please print)
Signature Title e•"6��.497 ASS,s'0&111'
(over)
DOH-1555 (02/2004)