Breece, George NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - . Burial - Transit Permit
A. Name First Middle Last Sex
George Breece Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 20, 2015 60 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 36 River Street
Manner of Death Natural Cause El Accident 0 Homicide 0 Suicide O Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Ruth Scribner,
Address
55 Beckett Road Whitehall, NY 12887
Death Certificate Filed District Numbe,L Register Number
City, Town or Village Hudson Falls S / Co `3
:.0 Burial Date Cemetery or Crematory
March 23, 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
by Common Destination
.. Carrier
t5 ❑ Disinterment Date Cemetery Address
tiv
=' Date Cemetery Address
Reinterment
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 remains described a ove as indicated.
qok
11 Date Issued 3' 3 -L20/S Registrar of Vital Statistics l`, v '
' (signature)
District Number,j'7 a 6, Place L&5-., - a
`';} ' I certify that the remains of the decedent identified at36ve were disposed of in accordance with this permit on: '
} Date of Disposition 03/23/2015 Place of Disposition Quaker Road Queensbury,NY 12804 Pwe',Vir,r✓��"4�d'k''
(address)
(section) number) (grave number)
'.�' Name of Sexton or r in Charge of Premises
_ � ���,�
/ (ple se print)
Signature Title 14i1 44 /,7-`
(over)
DOH-1555 (02/2004)