Knowlton, Stanley f
NEW YORK STATE DEPARTMENT OF HEALTH ft,
Vital Records Section r •. 4Burial - Transit Permit
Name First Middle Last Sex
Stanley Knowlton Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 4, 2015 70 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 ElAccident E Homicide ElSuicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Sponzo, Dr.
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls j I (,
Date Cemeteryor Crematory
El Burial .
January 8, 2015 Pine View Crematory
❑Entombment® Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
7, by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
r
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 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
•
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i / b/( 5 Registrar of Vital Statistics W c -y _ -A
(sign ure)
District Number boo 1 Place 6 .. `\SI 'J;
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 01/08/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) 4 (lot number) (grave number)
Name of Sexton or Person 'n Char a of Premises r. Semot
(pl ase print)
Signature Title Cl l
(over)
DOH-1555 (02/2004)