Williams, James NEW YORK STATE DEPARTMENT OF HEALTH : SQi
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
-4,444 James Shannon Williams Male
Date of Death Age If Veteran of U.S. Armed Forces, Z
September 21, 2014 93 War or Dates i
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address The Stanton Nusing and Rehabilitation
Manner of Death E Natural Cause ❑ Accident ❑ Homicide ❑ Suicide i l Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Patricia Auer,
Address
44
316 Carey Road Queensbury, NY 12804
Death Certificate Filed D mbgr 7e1gter Number
City, Town or Village Queensbury ' ))
❑Burial Date Cemetery or Crematory
- October 8, 2014 Pine View Crematory
❑Entombment Address
4 ®Lt
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
❑ Disinterment
Date Cemetery Address
f❑ Reinterment Date Cemetery Address
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 ins des abed o e as indicated.
' Registrar of Vital Statistics
Date Issued��c�-c���c�l-�-/ 9� ���
l (signature)
IV District NumbeS 9 c—) Place !6 i. O'1, a reS
• 4
• q I certify that the remains of the decedent identified above were dispos fin accor ance with this permit on:
Date of Disposition 10/08/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot nu Aber) (grave number)
Name of Sexton or Person in Charge of Premises .... .1-47
/J�� L--
(pase print)
SignatureTitle Cit4whIFAL
(over)
DOH-1555 (02/2004)