Dixon, Gary NEW YORK STATE DEPARTMENT OF HEALTH I. A t 5�c
Vital Records Section Burial - Transit Permit
i Name First Middle Last Sex
Gary Norman Dixon , Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 18, 2014 63 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls , Street Address Glens Falls Hospital
Manner of Death Natural Cause El Accident 0 Homicide El Suicide Undetermined Fl Pending
Circumstances Investigation
Medical Certifier Name Title
" >XI. Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number S Register Number
Ci Town or Villa a Glens Falls r 1
0 Burial Date Cemetery or Crematory
tl
September 23, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
�, Date Cemetery Address
lt, Li Disinterment
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
t Address
34 136 Main Street, South Glens Falls NY 12803
:Ir. of Funeral Firm Making Disposition or to Whom
•
Remains are Shipped, If Other than Above
fi Address
.a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 I a-z41LRegistrar of Vital Statistics Lf)C4k,6- ,
(signatu )
District Number S CDCt Place ( (Qmr,5 cf, k \ 5 ICJ"
/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/23/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) if (lot number)C (grave number)
Name of Sexton or Person in Charge of Premises Ar. r J nmei
( lease print)
Signature s-,. L Title M
(over)
DOH-1555 (02/2004)