Dimmick, Henry NEW YORK STATE DEPARTMENT OF HEALTH 1 131
Vital Records Section w Burial - Transit Permit
Name First Middle Last Sex
Henry A Dimmick Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/05/2012 80 years War or Dates Yes
I . Place of Death Hospital, Institution or
City, Towg d(iliOitXX Glens Falls Street Address Glens Falls Hospital
a Manner of Death in Natural Cause 0 Accident 0 Homicide ❑Suicide Undetermined Pending
tU Circumstances Investigation
fa
in Medical Certifier Name Title
O Michael Adams M n
Address
1448 Route 9, South Glens Falls, NY 12803
Death Certificate Filed District Number Register Number
VieTowytxx(il XX Glens Falls 5601 101
■Burial Date Cemetery or Crematory
❑Entombment 03/06/2012 . Pine View Crematorium
Address •
51Gyemation Queensbury, NY 12804
Date Place Removed
3 ❑Removal • and/or Held
and/or Address •
tt Hold
0 Date Point of
❑Transportation Shipment
d by Common Destination
Carrier
El Disinterment Date • Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
• Address
IX
til
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
IN Date Issued 03/06/2012 Registrar of Vital Statistics W CM e u\.,j
(signatur
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI• Date of Disposition ?•-�c-oabt2 Place of Disposition ?t yve 1 ec.J Ct•ewl& r t Li '1
a (address)
ILEA
in
CC (section) (lot number) (grave number)
0 i
'
ilk Name of Sexton or Person in Charge of Premises l z rV6\-i►1 rt1 el r"e
(please print)
Signature Title Cf�w•a t•- 41S4.
(over)
DOH-1555 (02/2004)