Pullen Jr, John NEW YORK STATE DEPARTMENT OF HEALTH ` ' ' ft 4, c7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John F. Pullen Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 8, 2015 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village South Glens Falls Street Address 4 Ferry Blvd
,- Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined IT❑ Pending
Circumstances Investigation
Medical Certifier Name Title John Esper, Dr.
it Address
325 Main Street Hudson Falls, NY 12839
Death Certificate Filed District Number Register Number
Ci Town or Village South Glens Falls
Date Cemetery
�'❑Burial September 10, 2015 P or Crematory
View Cremato
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
_,= Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
El Disinterment
Date Cemetery Address
❑ 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
1. Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re s describe ove indicated.
Date Issued 9 ) 1 S Registrar of Vital Statistics Q _ ,a(C
(signature)
District Number 45a4 Place i )k, ? /e/25 {, 51
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/10/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numb r) (grave number)
N::t
Stonor Person in Charge of Premises (please print)
Sure i....„ Title
(over)
DOH-1555 (02/2004)