Wicks, Roy NEW YORK STATE DEPARTMENT OF HEALTH ' - * # 3S0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roy Leroux Wicks Male
g Date of Death Age If Veteran of U.S. Armed Forces,
r July 7, 2012 64 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause E Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
jj Amy Hogan-Moulton, M.D. Dr.
Address
2 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 6j- ` 3 d2
❑Burial Date Cemetery or Crematory
July 9, 2012 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
A Date Place Removed
❑ Removal and/or Held
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
7 Name of Funeral Home M. B. Kilmer Funeral Home 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 desc ' a o as ted.
Date Issued (J7 00e)/z-- Registrar of Vital Statistics G2 t
_ (signature)
;TM: District Number .3*O/ Place />h o /?7/ � / '7' 2 10
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/09/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises trist'�.er &mil'
�1b (pl ase print)
Signature ( ,L - Title C11�C Mi'c o,
(over)
DOH-1555 (02/2004)