Bly, Kim NEW YORK STATE DEPARTMENT OF HEALTH -« Z4S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kim Alan Bly Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 16, 2015 60 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 10 River Street
Manner of Death❑ Natural Cause ❑ Accident E Homicide ❑ Suicide ❑ Undetermined ❑ Pending
,° Circumstances Investigation
Medical Certifier Name Title
Michael Sikirica,
Address
50 Broad Street Waterford, NY 12188
Deat ate File Dis rict umber�^/ egis er Number
City, Town o Village ✓ YJ _Q
gu Date Cemetery or Crematory
April 20, 2015 Pine View Crematory
0 Entombment Address
• ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
`` Hold
Date Point of
❑Transportation Shipment
`3 ° by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
• ` Permit Issued to Registration Number
• '' Name of Funeral Home M. B. Kilmer Funeral Home- FE 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 re ' s described abondicated.
Date Issued 9- I olaot 'Registrar of Vital Statistics 2 ri_t_..,
l(signature)
District Number -Cp Place t C�L-t--r- U--( CD L Sh
I certify that the remains of the decedent identified above were disposed of in ac rdance w' h this permit on:
Date of Disposition 04/20/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) A (lot number) (grave number)
Name of Sexton or Person in Charge of Premises n�' .�,
( lease print)
Signature 9 Title
(over)
DOH-1555 (02/2004)